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PRACTICAL 

OBSTETRICS 


BY 


THOMAS  WATTS  EDEN 

M.  D.,  C.  M.  Edin.,  F.  R.  C.  P.  Lond.,  F.  R.  C.  S.  Edin. 

OBSTETRIC  PHYSICIAN  AND  LECTURER  ON  MIDWIFERY  AND  GYNECOLOGY, 
CHARING  CROSS  HOSPITAL 
CONSULTING  PHYSICIAN  TO   QUEEN   CHARLOTTE'S  LYING-IN  HOSPITAL 
SURGEON  TO  IN-PATIENTS,   CHELSEA  HOSPITAL  FOR  WOMEN 


FOURTH  EDITION 


WITH  5  PLATES  AND  354  ILLUSTRATIONS  IN  THE  TEXT 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1915 


PREFACE   TO   THE    FOURTH 
EDITION 


N  preparing  the  present  edition  of  this  Manual  a  further 
increase  in  size  has  been  found  necessary  in  order  to 
include  the  advances  in  various  subjects  which  have  been 
made  during  the  last  three  years. 

The  introduction  of  Abderhalden's  Test,  and  the  progress 
which  has  been  made  in  our  knowledge  of  the  pregnancy- 
changes  in  the  endocrinous  glands,  has  altered  the  aspect  of 
the  General  Physiology  of  Pregnancy  so  much  that  this 
section  has  been  entirely  re- written.  The  description  of 
the  Toxaemias  of  Pregnancy,  and  of  the  obstetric  treatment 
of  Eclampsia,  has  also  been  completely  revised. 

The  valuable  work  of  British  obstetricians  in  recognising 
and  explaining  the  Local  Contraction  Ring  as  a  cause  of 
obstruction  in  labour  has  been  taken  advantage  of,  and  an 
attempt  made  to  classify  the  different  varieties  of  over- 
action  of  the  parturient  uterus.  The  treatment  of  Placenta 
Prsevia  has  also  been  completely  revised. 

Four  coloured  plates  are  included  in  this  edition,  which 
it  is  hoped  will  be  of  service  to  students  making  their  first 


vi  PREFACE   TO    THE   FOURTH  EDITION 

acquaintance  with  the  conditions  illustrated.  I  hare  to 
express  my  thanks  to  my  coUeague,  Dr.  Cuthbert  Lockyer, 
for  permission  to  make  use  of  two  interesting  specimens  in 
his  collection,  and  to  Dr.  Hubert  M.  Turnbull,  of  the  London 
Hospital;  for  the  microscopic  preparations  represented  in 
Plate  III. 

Thos.  Watts  Edex. 

26,  QuEEx  AxxE  Street,  W. 
1915. 


CONTENTS 


PAET   I 
NORMAL   PREGNANCY 

PAGE 

Ovulation 1 

Menstruation  .            6 

Fertilisation  and  Implantation  of  the  Ovum  ...  9 

Chorion  and  Placenta 27 

Amnion,  Umbilical  Cord,  and  Foetus 47 

The  Gravid  Uterus 62 

The  General  Physiology  of  Pregnancy    .         .         .         .71 

The  Diagnosis  of  Pregnancy  .         .         .         .         .         .     .  83 

Multiple  Pregnancy 97 

Management  of  Normal  Pregnancy 104 


PAET   II 

ABNORMAL   PREGNANCY 

Classification 106 

Albuminuria  and  Eclampsia 113 

Hyperemesis  Gravidarum 126 

Reflex  Disorders  of  Pregnancy 131 

Displacements  of  the  Gravid  Uterus         .         .         .         .132 
Malformations  of  tpie  Uterus  and  Pregnancy    .         .     .     141 

Pressure  Symptoms 142 

Uterine  Moles 143 

Decidual  Endometritis         .        .         .         .         .         .         .157 

Hydramnios ' 159 


viii  CONTENTS 

Page 

Diseases  of  the  Placenta    .         .         .         .         .         .         .181 

extka-ttteeixe  gestation 168 

Mateexax  Disoedeks  associated  WITH  Peegxaxct     .         .  199 

Ovarian  Tumoues  and  Pregnancy 214 

Tumours  of  the  Gravid  Uterus 215 

Abortion 218 

Death  and  Retention  of  Fcetus  in  Uteeo         .         .         .  236 


PAET   III 

A^0i?3/J.i   L ABOVE 

Clinicajl  Phenomena 241 

Anatomy  and  Physiology  of  the  First  and  Second  Stages  254 

Anatomy  and  Physiology  of  the  Thied  Stage    .        .     .  279 

Mechanism 284 

Management 308 

Occipito-posteeior  Positions  of  the  Vertex     .        .         .  337 


PART   IV 

ABJOEJIAL   L ABOVE 

Classification 343 

Face  Presentations  .........  344 

Brow  Presentations 356 

Breech  or  Pelvic  Presentations    .         .         .         .         ,     .  358 

Transverse  or  Shoulder  Presentations    ....  377 

Twin  Laboue 386 

Prolapse  of  the  Umbilical  Cord         .....  389 

Pelvic  Contraction .  394 

Eare  Forms  of  Contracted  Pelvis 423 

Abnormal  Conditions  of  the  Soft  Parts       .         .         .     .  433 

Abnormalities  in  the  Action  of  the  Uterus    .         .        .  442 

Obstructed  Labour .  455 


CONTENTS  ix 

PAGE 

Rupture  of  the  Uterus        .......     462 


Inversion  of  the  Uterus 
Ante-partum  Haemorrhage    . 
Non-expulsion  of  the  Placenta 
post-partum  haemorrhage    . 
Labour  complicated  by  Eclampsia 


480 
483 
510 
518 

527 


PAET   V 

THE   PUEBPEBIUM 

General  Physiology 542 

Process  of  Involution 548 

Management  of  the  Puerperium          .....  556 

Puerperal  Infection 563 

Clinical  Varieties  of  Puerperal  Infection       .         .         .575 

Local  Pelvic  Inflammation 594 

Phlegmasia  Alba  Dolens      .         .         .         .         .         .        .  598 

Inflammation  of  the  Mammary  Glands          .         .         .     .  603 

Puerperal  Hemorrhage        .         .         .         .         .         .         .  606 

Chorionepithelioma  .         .         .         .         .         .         .         .     .  607 

Reproductive  Insanity 611 

Sudden  Death  in  the  Puerperium 613 


PAET   VI 
THE   NEW-BOBN    CHILD 


General  Management    .         .         .         ..         .         .         .615 

Infant  Feeding          .         .         . 617 

Management  of  Premature  Infants 628 

Digestive  Disturbances .     ,  631 

Asphyxia  Neonatorum .  633 

Injuries  to  the  Head       ........  641 

Ophthalmia  Neonatorum                         .         .         .         .  646 

E.M.  h 


X  CONTENTS 

4 

PAET   YII 
OBSTETRIC   OPERATIONS 

VACJE 

Artificial  iNTERRUPXioisr  of  Pkegxanct          .        .        .     .  651 

Version 671 

Obstetric  Forceps 689 

CESAREAN  Section 719 

Craniotomy  ;  Decapitation  ;  Evisceration     .         .         .     .  737 

Symphysiotomy  ;  Pubtotomy 749 

Primary  Repair  of  the  Perineum 754 

INDEX 759 


Part  I. 
NOEMAL   PREGNANCY. 

Ovulation 

The  ovary  is  the  storehouse  in  which  egg-cells  (oocytes) 
are  preserved,  and  from  which  they  are  periodically  liberated 
during  the  years  comprised  between  puberty  and  the 
menopause.  Ovulation  is  the  process  by  which  oocytes  are 
discharged  from  their  protecting  chambers — the  Graafian 
follicles — ^into  the  peritoneal  cavity  ;  this  process  includes 
the  two  stages  of  maturation  (ripening)  and  dehiscence 
(rupture)  of  the  folhcles.  A  follicle  in  the  resting  phase 
{i.e.  before  ripening  has  commenced)  lies  deeply  in  the  cortical 
layer  of  the  ovary,  separated  from  the  surface  by  a  stratum 
of  ovarian  tissue  of  variable  thickness.  In  the  ripening 
process  two  changes  occur  :  (1)  it  first  approaches  the  surface, 
and  finally  becomes  partly  extruded,  forming  a  protuberance 
on  the  ovary,  the  germ -epithelial  covering  at  that  spot  being 
lost  ;  (2)  it  increases  greatly  in  size.  The  structure  of  a 
ripening  foUicle  is  shown  in  Fig.  1.  The  process  of  extrusion 
has  not  been  fully  studied,  but  there  occurs  an  undoubted 
displacement  of  the  enlarging  follicle  towards  the  surface. 
The  causes  of  rupture  are  also  obscure  and  probably  complex, 
and  many  different  views  concerning  them  have  been 
advanced.  A  great  increase  in  the  amount  of  liquor  foUiculi 
occurs  during  maturation,  partly  by  transudation  from  the 
congested  ovarian  vessels,  and  partly  perhaps  by  secretion 
from  the  proliferating  cells  of  the  granulosa  ;  towards  the 
end  of  the  process  haemorrhage  may  also  occur  into  the 
follicle,  causing  a  sudden  increase  in  tension  which  would 
easily  determine  rupture.  Clark  has  pointed  out  that  there 
is  great  proliferation  of  the  granulosa  cells  during  ovulation, 
which  he  beheves  also  increases  the  intra-foUicular  tension. 
In  addition,  degenerative  processes  of  the  nature  of  necrosis 
occur  in  that  part  of  the  wall  of  the  follicle  which  lies  exposed 

/  E.M.  1 


2  NORMAL  PREGNANCY 

upon  the  surface,  and  is  unsupported  by  the  ovarian  stroma, 
which  so  weaken  it  that  it  is  unable  to  resist  the  high  ten- 
sion within,  and  rupture  results.  Rupture  is  therefore  due 
to  weakening  from  degeneration  of  the  wall  of  the  follicle, 
combined  with  increased  intra-foUicular  tension. 

When  the  follicle  ruptures,  the  contained  fluid  escapes  and 


Discus    proligerus 


Tu.mca  albuginea 
of    ovary 


Tunica  fibrosa 
fmiter  coat  of  folLtcLe.) 


Tunica  vasculosa 
(irtrver  cooU   of  foLLicL^) 


Fig. 


1. — Ripening  Graafian  Follicle  protruding  upon  the  Surface  of  tlie 
Ovary.     (Bumm.J 


as  a  rule  carries  the  oocyte  with  it  into  the  peritoneal  cavity. 
The  discus  proligerus  is  usually, 'but  not  always,  attached  to 
the  deepest  part  of  the  wall  of  the  follicle.  Nagel  has  shown 
that  fatty  degeneration  of  the  granulosa  cells  occurs  during 
maturation,  and  this,  by  weakening  the  attachments  of  the 
oocyte,  no  doubt  assists  its  liberation  and  escape  from  the 
follicle.  Occasionally  two  and  sometimes  three  oocytes  are 
found  in  a  Graafian  follicle.     Sometimes  Graafian  follicles 


OVULATION  3 

may  rupture  without  detachment  of  the  oocyte  occurring  ; 
this  gives  the  opportunity  for  ovarian  pregnancy  to  arise  if 
spermatozoa  should  chance  to  enter  the  ruptured  folhcle 
(see  p.  169)  ;  otherwise  the  oocyte  would  perish  in  situ  and 
non-detachment  thus  become  a  possible  cause  of  sterility, 
but  we  have  no  definite  information  upon  this  point.  The 
human  oocyte  is  a  large  cell,  20()jji  in  diameter,  consisting  of 
the  zona  pellucida  or  striata  (cell-envelope),  the  vitellus  or 
yelk  consisting  of  coarsely  granular  protoplasm  (cell-body, 


^4^ 


3 


Fig.  2.— Human  Oocyte  showing  the  Corona  Eadiata,  Zona  Eadiala, 
G-ranular  Protoplasm,  Germinal  Vesicle,  and  Germinal  Spot. 
("Van  der  Stricht,  from  Galabin  and  Blacker.) 

cytoplasm),  the  germinal  vesicle  (nucleus),  and  the  germinal 
spot  (nucleolus).  An  oocyte  sometimes  contains  two  nuclei, 
and  the  nucleolus  is  not  infrequently  double.  The  human 
oocyte,  after  its  escape  from  the  follicle,  is  shown  in  Fig.  2 ; 
it  retains  a  covering  of  several  layers  of  cells  derived  from 
the  discus  proligerus,  which  serve  to  protect  it  during  its 
transit  to  the  Fallopian  tube  ;  in  the  tube  this  protective 
covering  disappears.  The  cells  forming  the  corona  radiata 
are  merely  somewhat  speciahsed  cells  of  the  same  origin  as 
those  of  the  discus  proligerus. 

After  its  discharge  from  the  ovary  the  oocyte  migrates  into 

i— 2 


4  NORMAL  PREGNANCY 

the  Fallopian  tube.  It  was  at  one  time  thought  that  during 
ovulation  the  fimbrise  of  the  abdominal  ostium  became  turgid 
like  erectile  tissue  and  spread  over  the  ovary  like  the  fingers 
of  the  hand,  so  that  the  ovum  was  discharged  directly  into 
the  mouth  of  the  tube  itself.  This  view  appears  to  rest 
upon  fancy,  and  is  opposed  to  established  clinical  facts.  We 
know  now  that  the  oocyte  does  not  always  enter  the  Fallopian 
tube  of  the  same  side,  but  may  pass  across  the  pelvic 
peritoneal  cavity  and  enter  the  opposite  tube.  This 
phenomenon,  known  as  '  external  wandering,'  has  been 
demonstrated  by  cases  in  which  a  woman  has  become 
pregnant  after  losing  the  ovary  of  one  side  and  the  tube  of 
the  other  ;  the  discharged  oocyte  must,  in  such  cases,  pass 
across  the  pouch  of  Douglas.  The  distance  between  the  ovary 
and  the  mouth  of  the  opposite  Fallopian  tube  is  not  great, 
and  may  be  reduced  by  the  pelvic  congestion  accompanying 
ovulation.  The  oocyte  has  no  locomotive  power  of  its 
own,  and  must  be  carried  by  peritoneal  currents  from  the 
ovary  to  the  tube.  There  is  no  difficulty  in  believing  that 
such  currents  exist  in  the  neighbourhood  of  the  abdominal 
ostia,  for  the  cilia  covering  the  mucous  surfaces  of  the 
fimbrise  work  towards  the  uterus  and  naturally  set  up 
currents  travelling  in  that  direction  in  the  thin  layer  of 
fluid  which  covers  the  peritoneum.  Their  existence  in 
lower  animals  has  been  actually  demonstrated  by  injecting 
insoluble  particles  into  the  peritoneal  cavity ;  some  of 
these  have  afterwards  been  found  in  the  tubes,  having  been 
carried  thither  by  peritoneal  currents.  When  once  the 
oocyte  has  reached  one  of  the  tubal  fimbrise,  it  is  probable 
that  peristaltic  contractions  of  the  tubal  muscle  play  a  part 
even  more  important  than  ciliary  action  in  passing  it  on  to 
the  uterus. 

After  the  Graafian  follicle  has  ruptured  and  discharged  its 
contents,  it  undergoes  important  changes  and  is  henceforth 
termed  the  corpus  luteum.  A  great  deal  of  attention  has 
recently  been  paid  to  both  the  structure  and  the  fiuictions  of 
this  body,  and  there  is  some  evidence  accumulating  that  it 
may  normally  exert  a  certain  controlling  influence  upon 
pregnancy,  and  that  morbid  conditions  of  the  developing 
ovum  within  the  uterus,  and  of  the  corpus  luteum  in  the 
ovary,  frequently  co-exist. 


CORPUS   LUTEUM  5 

The  cavity  of  the  ruptured  follicle  is  at  first  filled  up  with 
blood  effused  from  the  site  of  rupture  ;  the  degenerated 
granulosa  cells  are  mostly  cast  off,  their  place  being  taken  by 
many  layers  of  actively  proliferating  polygonal  cells  of 
epitheloid  character  in  which  a  yellow  pigment  called  lutein 
has  appeared.  These  cells  are  therefore  now  called  lutein 
cells.  So  well  marked  are  their  characters  that  their  presence 
in  a  structure  of  indeterminate  nature  is  sufficient  to  prove 
it  to  be  active  ovarian  tissue.     They  arise  either  from  the 


lAitein 
Layer 


Vessels  of 
tunica 
propria 


Fig.  3. — Corpus  luteura  three  weeks  after  Menstruation,  showing  the 
Central  Blood- clot,  the  Convoluted  Lutein  Layer,  and  the  Vascular 
Tunica  Propria.     (Bumm.) 


connective-tissue  cells  of  the  tunica  vasculosa  or  from  the 
membrana  granulosa.  Each  of  these  views  has  its  advocates, 
but  the  more  recent  observations  have  been  unanimously 
in  favour  of  their  origin  from  the  follicular  epithelium. 
Owing  to  the  collapse  of  the  follicle  after  evacuation  of  its 
contents  the  wall  becomes  convoluted  along  its  entire  length 
from  the  formation  of  folds,  and  the  lutein  layer  thus  comes 
to  acquire  its  characteristic  sinuous  outline  (Fig.  3).  Subse- 
quent changes  consist  in  the  absorption  of  the  central  blood- 
clot,  the  complete  occlusion  of  the  cavity  by  proliferating 
lutein  cells,  and  gradual  shrinkage  of  the  entire  body.     It  has 


6  NORMAL   PREGNANCY 

been  recently  shown  that  masses  of  lutein  cells  can  often  be 
found  scattered  through  the  ovarian  stroma  during  preg- 
nancy, so  that  their  function  is  probably  not  limited  to  the 
repair  of  the  ruptured  Graafian  follicle.  Soon  the  lutein  cells 
undergo  a  kind  of  hyaline  degeneration,  losing  their  nuclei 
and  cell  outlines,  and  becoming  transformed  into  structure- 
less masses.  These  masses  in  turn  are  replaced  by  connective 
tissue  which  invades  them  from  the  surrounding  ovarian 
stroma  ;  at  this  stage  it  is  usually  called  the  corpus  fihrosum 
or  corpus  albicans.  Frequently  the  corpus  albicans  becomes 
divided  into  portions  by  ingrowing  strands  of  stroma,  so 
that  a  considerable  number  of  white  bodies,  isolated  from 
one  another,  may  be  found  in  an  adult  ovary.  Finally  all 
trace  of  lutein  cells  disappears,  and  only  a  small  depressed 
cicatrix  remains  upon  the  surface  of  the  ovary  to  indicate 
the  previous  existence  of  the  corpus  luteum.  The  length  of 
time  occupied  by  these  changes  is  variable,  becoming  longer 
as  age  advances  ;  many  weeks  or  months  are  probably 
always  required  for  their  completion. 

During  pregnancy  the  corpus  luteimi  attains  a  greater  size 
than  when  pregnancy  does  not  occur  ;  it  may  continue  to 
increase  in  size,  probably  from  progressive  haemorrhage,  for 
three  or  four  months,  and  may  come  to  occupy  about  one- 
third  of  the  whole  ovarian  area.  It  then  gradually  undergoes 
the  retrograde  changes  just  described,  which  are  not  com- 
pleted until  after  the  termination  of  gestation.  The  large 
corpus  luteum  met  mth  in  pregnancy  was  formerly  called 
the  '  true  corpus  luteum,'  and  that  formed  when  pregnancy 
does  not  occur  the  '  false  corpus  luteum.'  Since  there  is 
no  essential  difference  between  them,  either  in  structure  or 
in  the  changes  they  undergo,  these  names  are  meaningless  ; 
the  one  is  no  more  '  false  '  nor  '  true  '  than  the  other. 

Menstruation 

It  is  undoubtedly  true  that  the  processes  of  ovulation  and 
menstruation  are  closely  related  to  one  another  ;  but  whether 
they  are  coincident  or  consecutive,  and,  if  consecutive,  which 
precedes  the  other,  we  do  not  know  with  certainty.  That 
menstruation  is  not  essential  to  the  occurrence  of  pregnancy, 
and  that  a  fertilised  ovum  may  be  successfully  implanted 


MENSTRUATION  7 

upon  a  quiescent  endometrium,  is  well  known  ;  for  preg- 
nancy may  occur  either  before  the  establishment  of  the 
menstrual  function  at  puberty,  after  the  menopause,  or 
during  a  temporary  suspension  of  menstruation  such  as  that 


Disintegrated-  Vy.  •^'   ;f'  jj. . 
svirface    -.tvyr-v-j"  •sij!-'.'.-^!^ 

Blood-       r-^^f\^W? 
vessels        •■■''■■'^^^'•''''''' 


Superficial 


epithelium 


■•!^/:y'Vl  Disintegrated 
auj-foLce 


.  ••    Gland- 

;  !:'*-';V''-    tubule 


.<) 


_Blood- 

vessel 


Fig.    4. — Vertical   Section   of  Endometrium  during  the   First  Day   of 
Menstruation.     (Schafer.) 

which  usually  accompanies  lactation.  There  is,  however, 
much  to  be  said  for  the  time-honoured  view  that  the  uterus 
is  in  some  way  prepared  by  the  menstrual  changes  for  the 
reception  of  the  fertilised  ovum  ;  for  regularity  of  the 
menstrual  function  is  the  rule  in  fertile  women,  and  clinical 


8  NOEMAL   PREGNANCY 

observations  indicate  that  conception,  although  it  may  occur 
at  any  point  in  the  menstrual  cycle,  is  most  likely  to  occur 
during  the  days  which  immediately  follow  a  menstrual 
period.  From  careful  chnical  observations  upon  cases  in 
which  the  ovaries  were  examined  in  the  course  of  opera- 
tions, Fraenkel  has  expressed  the  opinion  that  ovulation 
ordinarily  occurs  soon  after  the  close  of  a  menstrual  period. 
This  view  also  receives  support  from  the  fact  that  the  changes 
which  the  uterine  mucous  membrane  undergoes  diu-ing 
menstruation  present  certain  well-marked  resemblances  to 
those  which  immediately  follow  upon  conception  and  result 
in  the  formation  of  the  decidua.  So  marked  is  the  resem- 
blance that  many  writers  now  speak  of  the  endometrium 
during  menstruation  as  the  menstrual  decidua. 

The  anatomy  of  menstruation  has  been  recently  studied 
by  Gebhard,  Sellheim,  and  others  in  human  uteri  removed 
during  a  menstrual  period.  The  earhest  changes  appear  to 
be  hypersemia  and  swelling  of  the  mucosa,  associated  mth 
engorgement  of  blood-vessels,  which  is  most  marked  in  the 
superficial  capillaries  (Fig.  4).  The  glands  become  elongated 
and  irregularly  dilated,  presenting  a  somewhat  corkscrew 
outline  ;  when  seen  in  longitudinal  section  the  dilated  lumen 
is  irregularly  divided  by  transverse  septa  upon  which 
prohferating  epithelium  is  seen  ;  the  inter-glandular  con- 
nective tissue  increases  in  amount,  becomes  looser  in  texture, 
and  sometimes  shows  traces  of  infiltration  with  leucocytes 
(pre-menstrual  phase).  A  little  later  small  interstitial 
haemorrhages  appear,  situated  chiefly  beneath  the  superficial 
columnar  epithelium,  and  as  a  result  patches  of  these  cells 
become  thro"^Ti  off  ;  but  the  amount  of  tissue  lost  in  this 
way  is  very  small.  It  is  uncertain  whether  the  haemorrhages 
are  due  to  diapedesis,  or  to  degeneration  and  rupture  of  the 
walls  of  the  capillaries.  The  menstrual  flow  comes  in  part 
from  the  denuded  patches,  but  probably  the  whole  of  the 
greatly  congested  mucosa  bleeds  more  or  less.  In  addition  a 
large  amomit  of  mucus  is  produced  by  the  active  glands,  and 
this  substance  forms  a  considerable  part  of  the  bulk  of  the 
menstrual  fluid.  There  is  no  formation  of  large  ceUs  in  the 
connective  tissue,  such  as  occurs  in  pregnancy.  The  mucous 
membrane  of  the  cervix  takes  little  or  no  part  in  these 
changes.     If  an  ovum  becomes  fertihsed,  further  important 


FERTILISATION  9 

developments  occur  in  the  endometrium,  resulting  in  tlie 
formation  of  the  decidua  of  pregnancy  ;  if  not,  the  congestion 
subsides,  the  damaged  surface  is  repaired,  the  glands  become 
inactive,  and  the  mucous  membrane  passes  again  into  the 
phase  of  quiescence. 

The  most  important  difference  between  the  mucosa  during 
menstruation  and  the  decidua  of  pregnancy  is  the  formation 
in  the  latter  of  the  characteristic  decidual  cells  ;  in  most 
other  respects  the  resemblance  between  them  is  striking. 

Fertilisation  and  Implantation 

The  process  of  fertihsation  consists  in  the  union  of  the 
male  element  (spermatozoon  or  male  gamete)  with  the 
female  element  (oocyte  or  female  gamete).  From  what  we 
know  of  the  process  in  lower  mammals  there  is  reason  to 
believe  that  the  spermatozoon  and  oocyte  usually  meet  in 
the  Fallopian  tube.  We  have  seen  that  the  oocyte  may  be 
carried  into  the  tube  by  peritoneal  currents  and  then  passed 
on  by  the  action  of  the  ciliated  epithelium  and  tubal  muscle. 
The  spermatozoon  makes  its  way  upwards  from  the  vagina 
by  means  of  the  propelling  apparatus  with  which  it  is 
provided,  consisting  of  a  long  tail  which  acts  like  a  paddle 
in  driving  it  forward  through  the  thin  layer  of  fluid  which 
covers  the  mucous  membranes.  The  activity  of  the  sperma- 
tozoa is  very  great  in  certain  animals,  for  they  can  travel 
from  the  vagina  into  the  peritoneal  cavity  in  a  few  hours. 
It  is  somewhat  doubtful  whether  their  progress  is  opposed 
by  the  action  of  the  ciliated  epithelium,  for  the  existence 
of  ascending  currents  in  the  secretions  of  the  genital  tract 
has  been  demonstrated  by  Bond,  who  placed  insoluble 
particles  of  colouring-matter  in  the  vagina,  and  recovered 
them  in  the  Fallopian  tube  on  operation  a  few  days  later. 
The  time  occupied  by  the  transit  through  the  tube  in  the 
human  species  is  unknown,  but  from  comparative  observa- 
tions, it  is  believed  not  to  exceed  twenty-four  hours  (Teacher). 
It  is  possible  for  spermatozoa  to  lie  in  wait  for  the  oocyte  in 
the  Fallopian  tube  for  considerable  periods  ;  thus  they  have 
been  found  alive  in  a  human  Fallopian  tube  removed  three 
and  a  half  weeks  after  the  last  act  of  sexual  intercourse. 
Only  one  spermatozoon  is  required  for  the  fertilisation  of  an 


10 


NORMAL   PREGNANCY 


oocyte,  and  of  the  enormous  numbers  found  in  the  seminal 
fluid  nearly  all  must  perish  without  achieving  their  physio- 
logical destiny.  The  fertilised  egg-cell  is  termed  morpho- 
logically the  zygote  ;  clinically  it  is  convenient  to  call  it 
the  ovum,  a  term  which  may  be  applied  at  all  stages  of  its 
development. 

The  details  of  the  process  of  fertilisation  naturally  cannot 
be  studied  in  the  human  species  ;    most  of  what  we  know 


Pig.  5. — The  Process  of  Pertilisation  in  the  Mouse,  after  Sobotta.     (Von 

Winckel.) 

a.  Penetration  "by  a  spermatozoon,    h.  Formation  of  polar  body,  and  first  division  of 
segmentation  nucleus,    c.  Binary  division  of  the  ovum. 

comes  from  observations  upon  certain  of  the  echinoderms 
and  ascarides  which  possess  transparent  oocytes,  but  Sobotta 
has  recently  succeeded  in  studying  fertilisation  in  the  mouse. 
The  matter  can  only  be  very  briefly  referred  to  here. 

Immediately  before  the  union  of  the  spermatozoon  and 
oocyte,  certain  changes  occur  in  the  nucleus  (germinal  vesicle) 
of  the  latter,  resulting  in  the  extrusion  of  one  or  two  minute 
portions  of  its  substance,  with  a  covering  of  protoplasm, 
beneath  the  zona  radiata  ;  the  extruded  portions  are  termed 


FERTILISATION  11 

the  polar  globules,  but  their  significance  is  quite  unknown, 
and  they  soon  disappear.  The  polar  globules  carry  with 
them  one  half  of  the  chromatin  loops  (or  chromosomes) 
which  the  germinal  vesicle  originally  contained  ;  conse- 
quently the  latter  when  fertilised  contains  only  one  half  of 
its  proper  number.  It  is  possible  that  this  process  deter- 
mines the  occurrence  of  variations  in  hereditary  characters. 
As  the  human  oocyte  possesses  no  micropyle,  such  as  exists 
in  the  invertebrates,  the  spermatozoon  penetrates  (Fig.  5,  a) 
the  zona  radiata  (z.  pellucida),  and  when  the  head  has 
entered,  the  tail  separates  and  disappears.  The  human 
egg-cell  is  a  large  cell  200^  in  diameter,  and  visible  to  the 
naked  eye  ;  the  head  of  the  spermatozoon  measures  about 
5fjL  in  length.  Attention  has  recently  been  paid  to  the 
behaviour  of  the  nuclei  during  fertilisation,  and  observa- 
tions on  lower  animals  have  established  the  following  facts. 
The  included  head  of  the  spermatozoon  {male  pronucleus) 
and  the  germinal  vesicle  of  the  ovum  {female  pronucleus) 
each  divides  into  two,  and  active  karyokinetic  changes  occur. 
After  an  interval  the  four  nuclei  fuse  to  form  a  single  nuclear 
spindle  to  which  an  equal  number  of  chromatin  loops 
{chromosomes)  is  contributed  by  the  male  and  female  pro- 
nuclei. Every  cell  formed  from  the  fertilised  ovum  therefore 
contains  chromosomes  derived  originally  from  each  parent 
(Adami). 

The  cell  resulting  from  fusion  of  the  two  pronuclei  is 
the  fertilised  ovum  or  zygote.  The  fertilised  ovum  now  starts 
immediately  upon  a  career  of  extraordinary  activity  by 
which  all  the  organs  and  tissues  of  an  individual  human 
body  are  formed  from  it  by  cell-division  and  differentiation. 
The  process  of  cell-multiplication  in  its  earliest  stages  is 
known  as  the  segmentation  of  the  ovum.  The  segmentation 
nucleus  first  divides  into  halves,  which  recede  towards 
opposite  poles  of  the  cell  (Fig.  5,  6)  ;  an  equatorial  or  polar 
line  of  division  is  then  formed  between  them  which  divides 
the  entire  cytoplasm  in  two  (Fig.  5,  c).  The  same  process 
is  repeated  in  the  two  new  cells,  and  being  continued  in- 
definitely, the  ovum  multiplies  by  binary  division  into 
2,  4,  8,  16,  32,  &c.,  cells.  In  this  manner  a  solid  cluster  or 
globe  of  cells  is  formed,  called  the  muriform  body.  This 
body  next  becomes  converted  into  the  blastodermic  vesicle 


12 


NOR^IAL  PREGNANCY 


or  hlasfocysf  b}^  the  formation  of  fluid  in  the  centre,  which 
greatty  increases  its  size,  and  by  excentric  pressure  causes 
the  cells  to  become  flattened  and  arranged  around  the 
periphery.  This  process  has  been  described  by  Van  Beneden 
in  the  rabbit  (Fig.  6).  He  found  that  at  first  the  wall  of 
the  blastocyst  consisted  of  two  layers  of  cells,  the  outer 
complete,  the  inner  incomplete  ;  later  a  tliird  layer  of  cells 
was  developed' between  these  two  where  they  were  in  contact. 
These  three  layers  of  cells  constitute  the  trilaminar  blasto- 
derm, and  from  them  all  the  tissues  of  the  body  are  subse- 
quently developed.     The  outer  is  called  the  ectoderm,  the 

inner  the  entoderm,  the 
middle  layer  the  meso- 
derm. In  man  the  primi- 
tive ectoderm  is  of  great 
importance,  and  is  speci- 
ally designated  as  the 
trophohlast  {vide  infra). 
Immediateh"  preceding 
the  appearance  of  its  third 
layer  a  small  area  of 
thickening  is  formed  upon 
the  ectodermic  layer  of 
the  blastocyst,  which  is 
the  first  indication  of 
the  body  of  the  future 
embryo,  and  is  called  the 
embryonic  area  ;  a  shallow 
longitudinal  groove  soon  appears  along  this  area,  which 
is  the  first  foreshadowing  of  the  vertebral  column,  and 
is  called  the  primitive  groove.  The  embryonic  area,  with  its 
primitive  groove^  represents  that  portion  of  the  ectoderm 
which  is  alone  concerned  in  the  formation  of  the  body  of  the 
embryo  ;  it  is  known  as  the  embryonic  ectoderm  ;  the  re- 
mainder plays  a  different  part,  and  it  is  "with  this  portion  that 
we  are  now  chiefly  concerned.  Text-books  of  embryology 
must  be  referred  to  for  a  fuller  description  of  the  foregoing 
stages  and  for  an  account  of  the  development  of  the 
epidermal,  skeletal,  and  visceral  systems  ;  but  the  fate 
of  the  extra-emhryonic  portion  of  the  ovum  is  intimately 
concerned    with    the    nutrition    and    development    of    the 


Fig.  6. — ^Bi-laminar  Blastodermic 

Vesicle  of  Eabbit.     (Tan  Beneden.) 

ect.  Ectoderm  cells,    ont.  Entoderm  cells. 
z.'p.  Zona  pellucida. 


FCETAL   ENVELOPES 


13 


Head  b.  tail  folds 


Fusion  of  head  5»  tail   folds 

1 


foetus  in  utero,  and  is  therefore  of  immediate  importance  in 
obstetrics. 

At  this  stage  of  development  begins  the  formation  of 
the  special  foetal  envelopes,  the  chorion  and  amnion,  which 
fulfil  the  double  functions  of  nutrition  and  protection 
throughout  the  whole  period  of  intra-uterine  life.  In  the 
earhest  human  ova  which  have  been  described,  viz.  those 
of  Bryce-Teacher  and  Peters,  the  formation  of  these  mem- 
branes has  already  commenced.  They  appear  in  the  human 
species  probably  much  earlier  (relatively)  than  in  birds — 
the  creatures  in  whom  their  de- 
velopment has  been  most  care- 
fully studied. 

The  development  of  the  foetal 
envelopes  in  the  chick  is  as  follows. 
Chorion  and  amnion  are  developed 
together,  and  subsequently  differ- 
entiated for  the  special  functions 
they  have  to  fulfil.  They  are 
formed  from  folds  which  spring 
up  from  the  head  and  tail  ends, 
and  lateral  boundaries,  of  the  em- 
bryo, and  grow  over  its  dorsal 
surface.  These  folds  consist  of  a 
double  layer  of  epiblast  cells  with 
mesoblast  cells  between  .  them. 
The  inner  layer  of  the  blastoderm 
(hypoblast)  takes  no  share  in  the 
process.  Gradually  they  coalesce,  producing  a  membrane 
which  has  the  form  of  a  closed  hood  ;  it  consists  of  a  cen- 
tral layer  of  mesoblast  cells,  covered  externally  and  inter- 
nally by  a  layer  of  epiblast  cells  (Fig.  7).  This  single 
membrane  now  splits  into  two,  the  line  of  cleavage  passing 
through  the  centre  of  the  mesoblast  layer.  Thus  two 
membranes  are  formed,  the  outer  (further  from  the  em- 
bryonic area)  having  an  external  epiblastic  covering,  the 
inner  having  an  internal  epiblastic  covering  ;  the  former  is 
the  chorion,  the  latter  the  amnion. 

Recent  observations  upon  the  development  of  lower 
mammals  have  led  to  the  belief  that  a  different  mode  of 
development  of  the  foetal  membranes  occurs  in  them,  and 


Fig.  7. — Scheme  of  Develop- 
ment of  the  Amnion 
and  Chorion  in  the  Chick. 
(Von  Winckel.) 


14 


NORMAL   PREGNANCY 


the  appearances  found  in  the  earhest  human  ova  described 
make  it  probable  that  this  mode  of  development  obtains  in 
man  also.     This  method  is  diagrammatically  represented  in 


Aniniotic   sac 


Advancing  mesoblast 


Amniotic  sac 


Embryo 


Amniotic  sac 


d 

Choi-ion  Amniotic  sac 


Ventral 
3talk 


Fig.   8. — Scheme  of  Development  of  the  Amnion  in  Lower  Mammals, 
and  probably  in  Man.     (Von  Winckel.) 

Fig.  8.  Upon  a  part  of  the  surface  of  the  blastodermic 
vesicle  the  epiblast  splits,  forming  a  small  space  enclosed  by 
epiblast  cells  ;  this  represents  the  earliest  sign  of  the  amniotic 
sac  (Fig.  8,  a).     At  the  extremities  of  this  space  the  meso- 


AMNION  15 

blast  cells  proliferate,  but  more  markedly  at  one  end  than 
the  other.  The  epiblastic  floor  of  this  primitive  amniotic 
cavity  corresponds  to  the  embryonic  area,  and  the  special 
proliferation  of  the  mesoblast  takes  place  at  the  end  which 
ultimately  becomes  the  head  of  the  embryo.  The  meso- 
blast cells  at  the  head  end  now  penetrate  the  roof  of  the 
amniotic  cavity  and  split  it  into  two  layers,  the  process 
gradually  passing  over  to  the  tail  end  (Fig.  8,  b,  c).  In  this 
way  the  amniotic  cavity  becomes  completely  cut  off  by 
mesoblast  cells  from  the  epiblast  wall  of  the  blastodermic 
vesicle.  The  body  of  the  embryo  has  by  this  time  become 
outlined,  and,  with  its  amnion  and  umbilical  vesicle,  sinks 
away  from  the  surface  ;  the  layer  of  mesoblast  which  has 
formed  over  the  amnion  splits  in  two,  and  becomes  attached 
in  part  to  the  wall  of  the  blastodermic  vesicle,  in  part  to  the 
amnion.  The  blastodermic  wall,  consisting  now  of  an  outer 
epiblastic  and  an  inner  mesoblastic  layer,  becomes  the 
chorion  ;  the  zona  pellucida  has  disappeared.  The  embryo, 
with  its  amnion  and  umbilical  vesicle,  would  now  lie  free 
in  the  interior,  but  for  the  fact  that  a  mesoblastic  stalk 
attaches  its  tail  end  to  the  wall  of  the  blastodermic  vesicle  ; 
this  represents  the  ventral  stalk  (Fig.  8,  c,  d).  Thus  are 
formed  two  embryonic  coverings  ;  the  inner,  or  amnion,  is 
closed  from  the  outset  and  is  cut  out  of  the  primitive  epi- 
blast ;  the  outer  represents  the  primitive  epiblast  wall  of 
the  blastocyst  with  its  mesoblast  lining,  and  ultimately  this 
layer  becomes  the  chorion. 

When  this  method  of  development  obtains,  the  early 
embryo  is  in  this  way  cut  off — except  where  the  ventral 
stalk  is  formed  — from  the  periphery  of  the  developing  ovum. 
It  carries  with  it  a  certain  supply  of  nutritive  material 
contained  in  the  umbilical  vesicle.  This  structure  represents 
the  inner  entodermic  layer  of  the  blastocyst  cut  off  from 
the  periphery  by  the  proliferation  and  splitting  of  the 
mesoblast  layer.  In  birds  and  reptiles  the  umbilical  vesicle 
is  of  large  size  and  no  doubt  plays  an  important  part  in 
nutrition  ;  in  man  and  most  other  mammals  it  is  small  and 
unimportant.  As  we  shall  immediately  see,  changes  occur 
at  a  very  early  period  in  man  by  which  the  ovum  is  enabled 
to  obtain  the  nutriment  it  requires  directly  from  the  maternal 
tissues. 


16 


NORMAL   PREGNANCY 


The  earliest  stages  of  development  whicli  have  been 
observed  in  human  ova  appear  to  correspond  approximately 
to  the  stage  which  has  just  been  described.  A  human  ovum 
from  a  case  of  complete  abortion  has  recently  been  described 
by  Bryce  and  Teacher  which  represents  an  earlier  stage  of 
development  than  any  previously  described.  This  ovum  is 
shown  in  its  containing  strip  of  decidua  in  Fig.  9.  Circum- 
stances were  luiusually  favourable  for  the  determmation  of 
tlie  date  of  conception,  and  according  to  the  authors  the 
period  of  development  may  authori- 
tatively be  placed  at  about  fourteen 
dsijs,  the  limits  of  probability  being 
twelve  to  fifteen  days.  Before  the 
description  of  this  specimen,  an 
ovum  described  by  Peters  was  be- 
heved  to  be  the  earliest,  and  this 
was  estimated  by  him  at  three  to 
four  days'  development  only.  But 
the  Bryce-Teacher  ovum  is  obvi- 
ously an  earlier  stage  than  the  Peters 
ovum,  and  it  is  certain  that  the 
period  of  development  of  the  latter 
has  been  greatly  under-estimated  ; 
this  is  accoimted  for  in  part  by  the 
absence,  in  Peters'  case,  of  exact 
clinical  data,  the  specimen  being  a 
post-mortem  one  from  a  case  of 
suicide.  Prom  this  point  onwards 
we  can  accordmgly  proceed  upon  the 
results  of  direct  observation  upon  the 
human  ovum  instead  of  f ollo^dng  the  doubtful  guidance  of 
comparative  embrj^ology. 

The  general  structure  of  the  Bryce-Teacher  ovum  is 
diagrammatically  represented  in  Pig.  10,  and  that  of  Peters 
in  Fig.  1 1  ;  both  correspond  to  a  stage  considerably  further 
advanced  than  the  blastocyst  showTii  in  Fig.  6.  The  cells 
of  the  primitive  ectoderm  have  proliferated  and  now  form 
a  reticulated  layer  ;  the  amnion  has  been  cut  off  and 
included,  probably  in  the  manner  described  by  Sobotta. 
The  cells  of  the  entoderm  have  not  proliferated  to  the  same 
extent  as  those  of  the  ectoderm,  and  the  entodermic  vesicle 


Fig.  9.— Bryce  -  Teaclier 
Ovum  with  the  portion 
of  decidua  in  whicli  it 
was  imbedded.  The 
prominent  oval  lobule 
is  the  site  of  implan- 
tation. (Bryce  and 
Teacher.) 


BRYCE-TEACHER    OVUM 


17 


is  of  relatively  ^/ery  small  size.  In  the  figure  the  mesoderm 
forms  a  solid  mass  of  cells  filling  the  central  part  of  the  ovum 
and  surrounding  and  separating  the  entodermic  and  amniotic 
vesicles.  At  a  later  stage,  when  the  ovum  has  grown  larger, 
the  mesoderm  splits  into  two  layers,  the  outer  going  with 
the  trophoblast  to  form  the  chorion,  the  inner  going  with 
the  amnion  and  the  entodermic  vesicle.  The  sinking  of 
the  amniotic  vesicle    and    embryonic    entoderm    into    the 


n.z.  p.l.  cyt.     P.e.  cyt.  p.l.     n.z. 

I  I 


'-^--">:^, 


>v 


cap. 


pU. 


Fig.  10. — Diagram  of  the  Bryce-Teacher  Ovum.  The  cavity  of  the 
blastocyst  is  completely  filled  with  mesoblast  cells,  and  imbedded 
therein  are  the  amniotic  and  entodermic  vesicles.  P.e.,  point  of 
entrance;  cyt.,  cyto-trophoblast  ;  pi.,  plasmodi -trophoblast ;  n.z., 
necrotic  zone  of  decidua  ;  gl.,  gland  ;  cap.,  capillary  ;  pl^,  masses  of 
Plasmodium  invading  capillaries.     (Bryce  and  Teacher.) 

interior  of  the  blastocyst  is  a  process  which  is  not  at 
present  clearly  understood  in  the  human  ovum.  The  relation 
of  the  blastocyst  to  the  maternal  tissues  at  this  stage 
is  a  point  of  the  greatest  importance,  and  the  observations 
of  Hubrecht  (comparative),  of  Peters,  and  of  Bryce  and 
Teacher  permit  of  a  fairly  clear  account  being  now  given  of 
what  obtains  in  the  human  ovum. 

The  ovum  of  Bryce  and  Teacher,  and  that  of  Peters, 
were  both  found  to  be  completely  imbedded  in  the  decidua 

E.M.  2 


18 


NOmiAL   PREGNANCY 


O     !i 


Ph 


IMBEDDING   OF   THE   OVUM 


19 


(Figs.  10  and  11).  The  point  of  penetration  is  represented 
in  the  former  by  a  minute  depression  of  the  surface  where 
the  epithelium  is  lost,  and  a  small  area  of  blood  clot  is  seen  ; 
in  the. latter  it  is  represented  by  a  cap  of  fibrin  of  con- 
siderably larger  size.  How  did  the  ovum  penetrate  the 
decidua  and  bury  itself  completely  in  this  way  ?  The 
cells  of  the  trophoblast  are  capable  of  exerting  a  destruc- 
tive action  upon  the  maternal  tissues,  and  thus  a  bed  is 
excavated  in  which  the  ovum  lies  and  within  which  it  further 
develops.     After  imbedding,  the  trophoblast  shows  extra- 


Glan 
Vessel 


Embryo 

Fig.  12. — Imbedding  of  the  Human  Ovum.     (Diagrammatic, 
after  Peters.) 


ordinary  proliferative  activity,  while  the  other  parts  of  the 
blastocyst  remain  almost  quiescent.  Not  only  does  the 
trophoblast  area  enlarge  rapidly,  but  in  it  rapid  cell-multipli- 
cation also  occurs,  forming  a  thick  stratified  layer.  In 
both  the  Bryce-Teacher  and  Peters  ova  the  trophoblast  is 
differentiated  into  two  parts,  one  which  consists  of  nucleated 
protoplasmic  buds,  bands,  and  reticula  in  which  no  cell 
outlines  can  be  distinguished — the  jplasTnodi-trophohlast  or 
syncytium,  and  one  which  consists  of  definite  cells — the 
cyto-trophoblast.     The  plasmodial  bands  are  arranged  around 

2—2 


20  NORMAL   PREGNANCY 

the  blastocj^st  in  the  form  of  a  widely  spreading  network, 
into  the  spaces  of  which  pass  columns  of  the  cells  of  the 
cj^to-trophoblast  ;  m  the  meshes  which,  of  course,  form  an 
inter-communicating  system,  a  quantity  of  maternal  blood 
is  also  to  be  found.  The  protoplasm  of  the  plasmodi- 
trophoblast  is  minutely  vacuolated,  and  by  fusion  of  adjacent 
vacuoles  large  spaces  are  formed  in  the  plasmodia,  many 
of  which  are  seen  to  contain  maternal  blood.  The  space 
occupied  by  the  trophoblastic  network  has  been  excavated 
in  the  decidual  membrane,  and  the  steps  by  which  the 
excavation  is  carried  out  are  shown  diagrammatically  in 
Fig.  12.  It  is  beUeved  that  this  effect  is  produced  by  a 
solvent  action  exerted  upon  the  maternal  cells  by  a  proteo- 
lytic ferment  produced  by  the  trophoblast.  As  will  be  seen 
later  on  the  maternal  tissues  in  contact  with  the  ovum  show 
evidence  of  a  protective  reaction,  the  object  of  which  appears 
to  be  to  defend  themselves  against  encroachments. 

At  the  periphery  of  the  trophoblastic  zone  are  to  be  seen 
large  maternal  capillaries  which  have  been  penetrated  by 
Plasmodia  ;  the  latter  appear  to  have  destroyed  the  endothe- 
lium and  to  have  then  entered  into  the  lumen  of  the  vessel. 
This  process  explains  the  presence  of  maternal  blood  in  the 
spaces  of  the  plasmodial  network.  This  blood  does  not  coagu- 
late, and  there  is  no  doubt  that  it  serves  to  nourish  the  em- 
bryonic structures.  After  a  time  the  blood  begins  to  circulate 
through  the  meshes,  although  at  the  beginning  of  the  process 
it  is  necessarily  stagnant.  In  this  way  we  see  that  the 
nutrition  of  the  ovum  from  maternal  sources  is  provided  for 
at  a  very  early  period  of  development.  The  existence  of 
such  an  arrangement  as  this  in  the  mammahan  ovum  was 
first  described  by  Hubrecht  in  the  case  of  the  hedgehog, 
and  the  observations  of  Bryce  and  Teacher  have  demon- 
strated the  occurrence  of  a  precisely  similar  process  in 
man. 

It  will  be  apparent  that  at  this  stage  the  development  of 
the  body  of  the  embryo  has  hardly  begun,  the  blastocyst  con- 
sisting, apart  from  the  trophoblast  zone,  of  two  small  vesicles 
only,  one  representing  the  amniotic  vesicle,  an  ectodermal 
structure  which  has  been  cut  off  from  the  ectodermal  layer, 
and  the  other  a  smaU  entodennic  vesicle  which  represents  the 
original  inner  layer  of  the  tri-laminar  blastoderm.     The  space 


EMBRYONIC  AREA 


21 


between  them  is  occupied  by  a  mass  of  cells  representing  the 
mesoderm.  The  floor  of  the  amniotic  vesicle  is  much 
thicker  than  the  other  parts  (Fig.  13),  and  this  small  area 
represents  the  embryonic  area  (ectoderm),  and  indicates  the 
spot  at  which  the  body  of  the  embryo  will  be  laid  down. 
It  is  visible  clearly  in  the  ovum  of  Peters,  but  not  in  that 
of  Bryce-Teacher.  It  will  be  recollected  that  the  amniotic 
and   entodermic    vesicles   remain   in    connection   with   the 


Entoderm 


Mesoderm 


Ccelom 

Trophoblast 
Mesoderm 

-Entoderm 
-Amniotic  Cavity 
-Embryonic  Ectoderm 

Yolhi  Sac 


Fig.  13. — Embryonic  Areaiu  Peters's  Ovum.     (Grala,bin  and  Blacker.) 


trophoblast  by  a  mesodermic  process,  the  ventral  or  body 
stalk,  not  shown  in  Fig.  11,  but  represented  diagrammatically 
in  Fig.  8.  The  entodermic  vesicle  corresponds  with  the 
yolk  sac,  a  structure  of  great  importance  in  the  develop- 
ment of  birds  and  reptiles,  since  it  contains  a  store  of 
nutriment  upon  which  the  growing  ovum  draws.  In  mammals 
generally,  and  especially  in  man,  this  structure  is  unim- 
portant at  the  present  stage,  and  has  little  if  any  nutritive 
function. 


22 


NORMAL   PREGNANCY 


It  will  now  be  necessary  to  consider  the  maternal  struc- 
tures in  which  the  ovum  has  found  a  lodgment. 

Under  the  stimulus  of  the  implantation  of  the  fertilised 
ovum  m  the  uterus,  the  endometrium  of  the  whole  body  of 
the  organ  becomes  converted  mto  the  decidua,  but  the 
mucous  membrane  of  the  cervix,  as  a  rule,  remains  practically 
unaltered  (Fig.   14).     In  a  few  cases  definite  decidual  for- 


OvTiin    enclosed 
in   decidua, 
capaulaLris 


Fig.  14. 


-Uterus  with.  Oviun  of  Toui  "Weeks    (je^tatiou. 
(Bumm.) 


iSTatuval  Size. 


nation  has,  however,  been  observed  m  the  cervix.  This 
reaction  of  the  endometrium  in  pregnancy  is  of  great  interest 
and  will  be  referred  to  again  m  connection  with  tubal 
gestation.  As  the  ovum  enlarges,  it  becomes  possible  to 
speak  of  three  distinct  portions  of  the  decidua  :  (1)  a  large 
extent  of  the  membrane  which  is  not  in  direct  contact  with 
the  ovum  at  aU,  called  the  decidua  vera  (D.V.) ;  (2)  a  portion 
in  contact  Ttdth  the  base  of  the  ovum,  called  the  decidua, 
basalis  or  serotina  (D.B.) ;   and  (3)  a  portion  enclosmg  the 


DECIDUA 


23 


remainder  of  the  ovum,  termed  the  decidua  capsularis  or 
reflexa  (D.C.)  (Fig.  15).  The  term  '  decidua  refiexa '  indicates 
an  old  view  of  the  formation  of  this  portion  of  the  membrane, 
which  was  that  the  ovum  attached  itself  to  the  surface  of  the 


D.B. 


Fig.  15.— Uterus  with  Ovum  of  about  Ten  Weeks'  Gestation. 
(Galabin  and  Blacker.) 

decidua,  and  later  on  became  enclosed  by  the  growth  of  a  ring 
of  decidual  tissue  around  it,  which,  ultimately  meeting  over 
the  free  pole  of  the  ovum,  completely  enveloped  it.  We  now 
know  that  no  such  process  occurs  ;   the  ovum  is  imbedded  in 


24 


NORMAL   PREGNANCY 


the  decidua  from  the  outset ;  decidua  and  ovum  develop  pari 
passu  in  this  position,  thus  preservmg  the  original  relation  ; 
and  '  decidua  capsularis  '  is  therefore  a  better  term  than 
'  decidua  reflexa.'  The  decidua  basahs  is  the  area  upon  which 
the  placenta  is  subsequently  formed  in  the  great  majority  of 
mstances,  although  exceptions  occur  which  will  be  referred 


Dilated  gLaruL 


xzzo 

Decidu-cbl  siruis 


!FiG.  16. — Decidua  Vera:  Compact  Layer.  To  the  riglit  of  the  figure 
the  decidual  cells  are  closely  packed  and  polygonal ;  to  the  left 
they  are  looser,  and  oval  or  globular. 


to  later  on.  The  word  '  serotina  '  expresses  the  view  of 
Wilham  Hunter  that  the  ovum  entered  the  uterus  from  the 
tube  beneath  the  decidua,  raising  it  up  from  the  wall  of 
the  uterus  ;  later  on  a  new  formation  of  decidua  occurred  at 
the  base  of  the  ovum  {serotinus =lsite).  We  are  unacquainted 
with  the  functions  of  the  decidua  vera. 

All  j^arts  of  the  decidua  have  the  same  general  structure, 
and,   as  has  been  already  noted,   the  membrane  bears  a 


DECIDUA 


25 


certain  resemblance  to  the  menstruating  endometrium.  The 
principal  gross  change  which  has  occurred  is  the  differentiation 
of  the  decidua  into  two  layers,  the  superficial  co^npact  and  deep 
cavernous  layers.  The  latter  rests  directly  upon  the  uterine 
muscle.  The  deep  layer  is  rendered  cavernous  by  very 
marked,  active  dilatation  of  the  deep  portions  of  the  uterine 


Arteriole 


Fig.  17. — Decidua  Vera  :  Cavernous  Layer. 


glands  which  form  spaces  of  varied  size  and  shape,  with  an 
epithelial  lining  showing  evidences  of  active  cell  proliferation 
(Fig.  17).  The  superficial  layer  consists  of  a  compact  mass 
of  '  decidual  cells  '  in  which  appear  here  and  there  dilated 
capillaries — the  '  decidual  sinuses  '  (Fig.  16).  The  greater 
part  of  the  surface  epithelium  is  lost,  and  very  few  glands 
can  be  seen  in  this  layer.  Where  chorionic  villi  come  in 
contact  with  the  decidua  certain  striking  structural  changes 


26  NORMAL  PREGNANCY 

occur  which  will  be  referred  to  later  on.  The  cavernous 
layer  is  well  marked  in  the  decidua  basalis,  but  is  not  nearly 
so  well  differentiated  in  the  other  parts  of  the  decidua.  The 
'  decidual  cells  '  are  specialised  connective-tissue  cells  ; 
in  most  situations  they  are  closely  packed  together  and 
become  polygonal  from  pressure  ;  where  the  arrangement  is 
looser  they  assume  a  spherical  or  oval  shape.  Their  nuclei 
are  large  and  globular.  Among  the.  decidual  cells  are  seen 
numerous  small  interstitial  haemorrhages,  and  here  and  there 
some  leucocytic  infiltration  (Fig.  16).  The  differences 
between  the  decidua  and  the  normal  endometrium  may  be 
briefly  summed  up  as  follows  :  (1)  formation  of  decidual 
cells  ;  (2)  hypertrophy  and  dilatation  of  the  deepest  por- 
tions of  the  glands  ;  (3)  increased  vascularity,  leading  to 
formation  of  widely  dilated  capillaries  or  '  sinuses,'  and 
interstitial  haemorrhages  ;  (4)  extensive  loss  of  the  surface 
epithelium  ;  (5)  division  into  two  layers — the  superficial 
compact,  the  deep  cavernous  ;  (6)  great  increase  in  thickness 
— endometrium  about  2V  of  an  inch,  decidua  f  to  |  of  an 
inch. 

The  decidua  vera  increases  progressively  in  thickness 
until  it  attains  its  maximum  at  about  the  end  of  the  second 
month.  By  the  end  of  the  third  month  the  decidua  cap- 
sularis  and  decidua  vera  have  been  brought  into  apposition 
with  one  another  by  the  rapid  increase  which  has  taken 
place  in  the  size  of  the  ovum.  It  appears  probable  that 
during  the  early  months  the  decidua  exercises  a  certain 
protective  function  towards  the  maternal  organism.  It 
arrests  the  invasion  of  the  trophoblast,  and  the  active 
cellular  reaction  which  occurs  later  on  wherever  chorionic 
viUi  meet  it  {vide  infra),  is  probably  to  be  understood  as  a 
protective  reaction.  The  main  function  of  the  decidua,  how- 
ever, is  to  afford  a  nidus  in  which  the  ovum  may  be  imbedded 
and  thus  protected  against  traumatism,  which  the  delicacy 
of  its  structures  renders  it  specially  prone  to  suffer  from. 
During  the  fourth  month  these  two  layers  become  fused, 
and  at  term  they  have  become  extensively  atrophied  from 
pressure  so  as  to  be  indistinguishable  as  a  double  layer. 
The  decidua  basalis  becomes  the  maternal  portion  of  the 
placenta,  but  conserves  its  characteristic  appearances  in  the 
cavernous  layer  till  term. 


CHORION 


27 


Chorion  and  Placenta 

We  have  now  followed  the  steps  which  have  been  demon- 
strated in  the  imbedding  of  the  fertilised  ovum  in  the  decidua, 
and  in  the  formation  of  the  trophoblast.  These  arrange- 
ments provide  for  the  nutrition  of  the  ovum  at  this  early 
stage  by  bringing  its  outer  covering  into  direct  contact  with 
free  maternal  blood.  The  next  stage  is  the  formation  of  the 
chorion  or  specialised  outer  foetal  envelope  ;  this  structure  is 
formed  directly  from  the  trophoblast,  and  accordingly  comes 
to  represent,  at  this  stage,  the  outer  ectodermal  layer  of  the 
primitive  blastoderm.  The  transformation  of  the  tropho- 
blast into  the  chorion  is  brought  about  by  the  formation  of 


Embryonic  area 


Amnion 


Chorion 


Chorion 


Yolli  sac 


Allantoic 


Fig.  18,— Spee's  Human  Ovum  from  Early  Part  of  Second  Week. 
(Galabin  and  Blacker.) 

villi  which  replace  the  irregular  network  of  plasmodial  cells 
and  processes  of  which  the  former  consists.  The  beginning 
of  this  stage  is  represented  in  Spee's  ova  shown  in  Figs.  18 
and  19.  The  general  relations  of  the  various  parts  of  the 
blastocyst  are  here  the  same  as  in  the  ova  of  Bryce-Teacher 
and  Peters,  but  two  points  of  progress  are  apparent. 
Firstly,  the  outer  envelope  is  beset  with  branching  processes 
or  villi,  consisting  of  an  outer  epiblastic  covering,  and  an 
inner  mesoblastic  core  of  connective  tissue  which  soon 
becomes  highly  vascularised.  Secondly,  the  embryonic  area 
with  its  amniotic  and  entodermic  vesicles  is  connected  with 
the  outer  envelope  by  a  mesoblastic  process  which  is  the 
precursor  of  the  umbilical  cord  ;  it  is  known  as  the  abdominal 
pedicle  or  ventral  stalk,  since  it  comes,  at  a  later  stage,  to  be 
attached  to  the  ventral  surface  of  the  body  of  the  embryo. 


28 


NORIMAL   PREGNANCY 


The  relatively  small  size  of  the  amnion  is  well  shown,  and  it 
will  be  observed  that  the  arrangement  closely  resembles  the 
diagrammatic  representation  of  the  development  of  the 
amnion  shown  in  Fig.  8.  Plate  I  represents  an  ovum  of 
three  weeks'  development  which  has  been  described  by 
Waterston.  It  follows  closely  upon  that  of  Graf  Spee,  and 
is  clearly  more  advanced  than  that  of  Peters,  for  vilK  are 


Chorionic  villi 


Me&odermr 


^^essela 


Fig.  19. — Sao;ittal  Section  of  Spee's  Ovum ;  a  little  more  advanced  than 
Fig.  IS.     (Graf  Spee.) 


well  developed  in  it.  The  preponderating  size  of  the 
chorionic  vesicle  is  well  seen  ;  the  small  size  and  incomplete 
formation  of  the  amnion,  and  the  large  size  of  the  yolk  sac 
are  points  which  are  better  seen  in  this  ovum  than  in  anj 
other  which  we  possess.  It  wiU  be  seen  also  that  vessels 
are  present  in  the  body  of  the  embryo  and  the  yolk  sac  : 
the  chorionic  membrane  and  viUi  are  not  vascularised,  but 


Q  S 


S^ 


CHORIO-DECIDUAL   SPACE 


29 


the  ventral  stalk  contains  vessels  which  will  shortly  reach  the 
chorion  and  supply  it. 

The  relations  of  the  chorion  to  the  decidua  must  now 
receive  attention,  and  it  will  become  evident  that  important 
developments  have  occurred  in  the  relation  of  the  embryonic 
and  maternal  structures  to  one  another. 

These  relations  can  best  be  seen,  however,  in  another 


Decidua 
capsular  IS 


Maternal 

Cd-plUcLTU 

X 


ChDnonic   vilh 


Chono  -  decid  u  al 
5pace 


ovum  of  a  somewhat  later  period — that  of  Leopold,  shown  in 
Fig.  20.  This  ovum,  which  was  examined  in  situ,  was  at 
first  estimated  to  belong  to  the  end  of  the  first  week  of 
development  ;  it  is,  however,  in  all  probability  very  con- 
siderably older  than  this,  and  is  estimated  by  Teacher  at 
about  seventeen  to  eighteen  days.  The  manner  in  which  the 
relations  of  the  ovum  to  the  decidua  are  developed  has  been 
shown  diagrammatically  in  Fig.  12. 

In  Leopold's  ovum  it  is  apparent  that  the  decidua  and  the 


30  NORMAL   PREGNANCY 

chorion  are  separated  by  a  considerable  space  except  at  the 
two  poles  ;  at  the  base  a  process  of  the  decidua  basalis 
du'ectl}^  supports  it  ;  at  the  free  pole  chorion  and  decidua  are 
united  over  quite  a  considerable  area,  corresponding  to  the 
position  of  the  fibrin  cap  in  Peters's  ovum.  The  space 
between  chorion  and  decidua  is  termed  the  chorio-decidual 
space,  and  is  occupied  by  numerous  viUi,  seen  in  section  in 
the  figure,  most  of  which  contain  blood-vessels.  Some  are 
free,  some  are  attached  to  the  decidua  by  then'  tips  ;  in  the 
spaces  between  them  lies  fresh  maternal  blood,  and  one  or 
two  delicate  maternal  capillaries  can  be  seen  opening  into 
the  chorio-decidual  space.  The  chorio-decidual  space  repre- 
sents the  area  over  which  decidual  tissue  has  been  destroyed 
by  the  agency  of  the  trophoblast  ;  the  chorionic  villi  have 
replaced  the  irregular  network  of  plasmodial  processes  and 
cellular  columns  which  constituted  the  trophoblast  ;  and 
further  the  villi  have  become  vascularised  by  the  ingrowth  of 
blood-vessels  from  the  growmg  embryo.  This  is  obviously 
a  great  advance  towards  the  formation  of  a  placenta  with  a 
double,  i.e.  foetal  and  maternal,  cii^culation.  In  a  second, 
somewhat  older  ovum,  Leopold  found  that  the  Avhole  surface 
of  the  chorion  was  beset  with  viUi,  the  chorio-decidual  space 
being  continuous  around  the  entu"e  ovum.  Even  if  there  is 
no  definite  maternal  ckculation  through  the  chorio-decidual 
space,  the  villi  are  certainly  vascularised,  and  nutritive 
materials  from  the  effused  maternal  blood  can  be  taken  uj) 
b}'^  osmosis  into  the  foetal  ch'culation.  The  arrangement 
corresponds,  in  fact,  to  a  simple  form  of  diffused  placenta 
surrounding  the  whole  ovum,  and  shows  a  distinct  advance 
in  construction  upon  the  trophoblast  previously  described. 
In  this  manner  the  nutrition  of  the  ovum  is  carried  on,  while 
time  is  gained  for  the  formation  and  growth  of  the  highly 
complex  discoidal  placenta.  It  is  not  until  the  end  of  the 
sixth  week  that  this  placenta  begins  definitely  to  be  formed, 
so  that  the  chorio-decidual  spa.ce  plays  an  important  part 
in  the  nutrition  of  the  ovum  for  a  considerable  period,  from 
the  third  to  the  sixth  week. 

The  structure  of  the  chorion  during  the  first  six  weeks 
of  development  must  now  be  more  fuUy  described.  The 
chorion  at  this  period  is  everywhere  covered  with  complex 
branching  vOli.     In  their  earhest  form  the  viUi  are  short, 


CHORIONIC   VILLI  31 

thick  columns  which  subdivide  in  a  digitate  manner  (Fig.  19). 
Later  on  they  become  complex,  arborescent  structures,  the 
main  divisions  of  which  contain  large  vessels  ;  only  the  ter- 
minal and  sub -terminal  branches  are  then  called  villi.  These 
however  constitute  the  great  bulk  of  the  developed  chorion 
and  are  definitely  arranged  in  clusters  in  an  ovum  of  about 
six  weeks'  development  (Fig.  21),  and  form  a  thick  layer  of 


Fig.  21.^ — -Complete  Ovum  3-5  cm.  x  4-25  cm.,  about  the  sixtli 
week  of  development.  The  chorion  is  beset  with  villi  which 
are  ari-anged  in  clusters.  The  dark  area  in  the  upper  part 
is  blood-clot.     (Charing  Cross  Hospital  Museum.) 

delicate  branching  processes  springing  from  the  outer 
surface  of  the  chorion,  which  in  places  can  be  seen  as  a  smooth 
membrane.  The  chorion  consists  of  three  main  elements  : 
(1)  an  epithelial  covering  ;  (2)  a  connective-tissue  stroma  ; 
(3)  a  system  of  blood-vessels. 

(1)  The  chorionic  epithelium  is  the  outer  covering.  It 
consists  of  two  distinct  layers — an  outer  layer  of  multi- 
nucleated protoplasm,  undifferentiated  into  cells  ;    and  an 


32 


NORMAL  PREGNANCY 


inner  layer  of  large  well-defined  cells  with  oval  nuclei, 
frequently  resting  upon  a  distinct  basement  membrane 
(Fig.  23).  These  layers  are  respectively  derived  from  the 
plasmodi-trophoblast  and  cyto-trophoblast  previously  de- 
scribed in  connection  with  the  imbedding  of  the  blastocyst. 
The  outer  layer  is  termed  the  syncytium,   or  simply  the 


o^^ 


•-^ 


y^5>- .-•'** 


«8^%4§» 


^^-< 


* 


^^^.S.'tf^. 


Fig.  22. — Villi  from  a  six  weeks'  ovum,  showing  the  proliferation  of  the 
sync}-tium  (low  power), 


plasmodial  layer  ;  the  latter  is  termed  the  cellular  layer,  ov, 
after  its  discoverer,  the  layer  of  Langhans.  Both  layers  are 
of  ectodermal  or  epiblastic  origin,  although  for  a  long  time 
it  was  thought  that  the  outer  layer  was  derived  from  the 
decidua  and  was  therefore  maternal.  During  the  first 
two  months  of  development  the  chorionic  epithelium 
displays   great  proliferative   activity,   both  layers   partici- 


CHORIONIC   EPITHELIUM 


33 


pating,  but  especially  the  syncytium.  The  latter  structure 
throws  out  enormous  numbers  of  plasmodial  buds  and  pro- 
cesses in  the  form  of  knobs,  club-shaped  outgrowths,  or 
slender  elongated  bands  ;  in  a  microscopic  section  many  of 
these  buds  are  seen  cut  across  in  transverse  section  and 
appear  as  independent  areas  or  islets  of  nucleated  Plas- 
modium (Fig.  22).  In  earlier  descriptions  of  the  placenta 
they  were  described  as  '  giant  cells.'  The  cells  of  the  deep 
layer  also  proliferate  actively,  especially  at  the  sides  and 


Fig.  23.— Edge  of  a  Villus  from  the  same  specimen 
as  Fig.  22,  showing  the  double  layer  of  cells 
of  which  the  epithelium,  consists  (high  power). 

tips  of  the  villi  ;  they  appear  as  clusters  of  cells  usually 
covered  with  a  thin  layer  of  plasmodium.  These  also  may 
be  seen  cut  across  in  transverse  section,  and  are  distinguished 
as  the  '  islets  of  Langhans  '  ;  at  one  time  they  were  regarded 
as  decidual  in  origin.  A  characteristic  feature  of  the  young 
syncytium  is  extensive  vacuolation  ;  it  will  be  recollected 
that  this  point  is  also  to  be  observed  in  the  trophoblast.  At 
first  numbers  of  minute  spaces  are  formed  in  the  proto- 
plasm, which  increase  in  size  by  fusion,  and  ultimately 
form  large  spaces.      In  this  way   syncytial  buds  become 

E.M.  3 


34  NORMAL   PREGNANCY 

excavated  so  that  the  subjacent  mesoblast  is  able  to  grow  out 
into  them,  carrying  with  it  blood-vessels,  and  thus  the  bud 
is  converted  into  a  new  villus. 

The  syncytium  contains  a  large  amount  of  glycogen  and 
finely  divided  fat,  the  function  of  which  is  not  clearly  under- 
stood.    It  has  been  already  mentioned  that  the  trophoblast 


Fig.  24. — Fully  formed  Villus  from  a  Placenta  at  term,  showing  wide 
capillaries.  It  will  be  noted  also  that  the  epithelial  covering 
is  atrophied  and  incomplete. 

exerts  a  destructive  (necrotic)  action  on  the  maternal  tissues 
with  which  it  comes  in  contact,  and  that  this  effect  is  often 
plainly  seen  in  the  case  of  maternal  vessels  into  which 
syncytial  buds  have  penetrated  after  eroding  the  walls.  This 
action  can  be  observed  also  in  the  young  placenta  where 
chorionic  and  maternal  tissues  come  in  contact  with  one 
another.     An  interesting  result  often  ensues,  viz.  small  buds 


THE   VILLI  35 

and  processes  of  syncytium  become  broken  off  and  carried  by 
the  blood-stream  into  distant  parts,  where  they  are  arrested 
as  emboli  in  capillary  vessels.  More  rarely  a  complete  villus 
may  thus  form  an  embolus  in  the  lung  or  some  other  organ. 
In  morbid  conditions  of  pregnancy  this  passage  of  fragments 
of  chorionic  tissue,  chiefly  epithelial,  into  the  maternal  blood- 
stream is  much  more  abundant  than  in  normal  pregnancy, 
and  this  subject  will  be  referred  to  again  in  connection  with 
eclampsia. 

(2)  The  stroma  is  a  delicate  reticulum  of  connective 
tissue,  embryonic  in  type,  which  supports  the  blood-vessels  ; 
in  the  larger  chorionic  branches  it  is  more  compact  than  in 
the  terminal  branches  or  villi.  The  interstices  form  a  system 
of  anastomosing  channels  which  are  probably  of  the  nature  of 
lymphatics. 

(3)  The  blood-vessels  are  the  terminal  ramifications  of  the 
umbilical  arteries  and  veins  ;  in  the  larger  chorionic  branches 
they  lie  in  the  axis  ;  in  the  terminal  villi  capillaries  only  are 
found,  and  these  lie  immediately  beneath  the  epithelium, 
where  they  run  a  tortuous  course  and  anastomose  freely.  In 
an  injected  placenta,  a  tiny  thread  of  colouring-matter  can 
often  be  traced  from  a  villus  into  one  of  its  syncytial  buds, 
showing  the  commencement  of  vascularisation.  The  fully 
developed  villi  are  extremely  vascular,  and  often  appear 
under  the  microscope  to  be  as  full  of  blood  as  a  soaked 
sponge  (see  Fig.  24)  ;  between  the  foetal  blood  in  the  villi 
and  the  maternal  blood  in  the  chorio-decidual  space  nothing 
intervenes  except  the  chorionic  epithelium  and  the  endo- 
thelium of  the  foetal  capillary  wall. 

The  chorion  retains  the  characters  just  described  until  the 
second  half  of  the  period  of  gestation,  when  changes  in  its 
structure  occur  which  will  be  referred  to  later  on.  The 
chorio-decidual  relations  undergo  no  marked  change  until 
the  latter  half  of  the  second  month,  when  the  formation  of 
the  discoidal  placenta  is  begun.  The  process  simply  consists 
in  the  specialisation  of  a  part  of  the  chorion  to  perform  the 
work  previously  done  by  the  whole.  As  the  placenta  develops 
the  villi  covering  the  general  surface  of  the  chorion  become 
devascularised  and  undergo  atrophy  early  in  the  third  month. 
At  the  placental  site — the  base  of  the  ovum,  the  villi  increase 
greatly  in  size,  number,  and  complexity,  while  important 

3—2 


36 


NORMAL  PREGNANCY 


changes  also  occur  in  the  underlying  decidua.  A  diminution 
in  the  total  area  of  the  villous  chorion  is  thus  compensated  by 
the  specialisation  of  a  part  of  it. 

The  changes  which  now  occur  at  the  placental  site  lead 
up  to  three  important  results  :    (I)  by  repeated  subdivision 


Large  chorionic  stems 
with  vessels 


Fibrin 


Fitoirin 


Fig.  25. — Fully  developed  Placenta  of  the  eighth  month.  In  the  larger 
stem  is  an  arterjr,  in  section,  with  the  lumen  narrowed  by 
endarteritis. 


enormous  numbers  of  chorionic  stems  and  terminal  divisions 
(villi)  are  produced ;  (2)  firm  attachments  are  formed  between 
the  foetal  and  maternal  elements  ;  (3)  a  definite  maternal 
circulation  is  established  through  that  portion  of  the  chorio- 
decidual  space  which  is  in  relation  to  the  decidua  basalis. 

( 1 )  The  enormous  numbers  of  villi  present  in  the  placenta 
will  be  understood  from  an  examination  of  Fig.  27,  which 


THE   VILLI  37 

represents  a  vertical  section  through  the  entire  placenta. 
The  larger  chorionic  stems  spring  from  the  chorionic 
membrane  underlying  the  amnion,  and,  dividing  irregu- 
larly, terminate  in  an  indefinite  number  of  small  divisions 
termed  villi.  Some  of  these  stems  traverse  the  whole 
thickness   of    the     placenta,    so     that    their   terminal   villi 


Fig.  26. — Placental  Villus  attached  to  the  Decidua.     The  proliferating 
cells  of  Langhans'  layer  have  invaded  the  decidual  tissues. 

reach  the  decidua  basalis.  Both  villi  and  larger  branches 
appear  in  sections  to  be  of  diverse  size  and  shape  (Fig.  25), 
but  this  is  partly  due  to  the  varying  angles  at  which  they 
have  been  cut.  The  larger  branches  all  contain  large 
vessels,  and  through  the  centre  of  the  largest  of  all  one  or 
more  arteries  and  veins,  running  side  by  side,  can  usually 
be  traced.  The  viUi  are  not  in  contact  with  one  another,  but 
are  separated  by  spaces — -the  intervillous  spaces.     It  will  be 


38 


NORMAL  PREGNANCY 


obvious  that  these  spaces  form  throughout  the  placenta  an 
elaborate  system  of  branching  channels  allowing  free  com- 


FiG.  27. — Section  through  a  Seven  Months'  Placenta  in  sita.     (Minot.) 

munication  to  take  place  between  one  part  of  the  organ  and 
another.  Through  the  general  system  of  intervillous  spaces 
the  maternal  circulation  is  carried  on,  so  that  a  gentle  stream 


The  villi 


39i 


of  maternal  blood  is  perpetually  flowing  around  the  villi. 
When  the  large  numbers  of  these  villi  are  borne  in  mind,  it 
will  be  evident  that  the  superficial  area  of  contact  between 
the  foetal  structures  and  the  maternal  blood  in  the  placenta 
is  of  very  great  extent.  In  many  places  adjacent  viUi 
become  united  to  one  another  by  small  deposits  of  fibrin  ; 
isolated  syncytial  masses  are  seen  here  and  there,  and  in 
places  clusters  of  nuclei,  representing  areas  of  proliferating 
Langhans'  cells,  can  be  seen  on  the  surface  of  a  villus  or  free 
in  the  intervillous  spaces  (islets  of  Langhans).  A  good  deal 
of  maternal  blood  can  be  found  in  the  intervillous  spaces 


Chorion 


Villi, 


\'''':-Ju'''i\'J-  Maternal 
.-.■^  --^"■'ij'/         vein. 

Maternal 
artery. 

Fig.  28. — Scheme  of  the  Placental  Attachments. 


when  care  is  taken  to  prevent  it  from  escaping  during  the 
preparation  of  the  tissue  for  microscopic  section. 

(2)  The  'placental  attachments  consist  of  (a)  a  firm  union 
between  large  numbers  of  villi  and  the  surface  of  the  decidua 
basalis,  and  (6)  a  special  development  of  the  decidua  at  the 
margins  of  the  organ,  {a)  The  attachment  of  the  villi  to 
the  decidua  presents  some  interesting  features.  Where  the 
two  come  into  contact,  the  syncytial  layer  of  the  chorionic 
epithelium  disappears,  and  a  marked  proliferation  of  the 
cells  of  Langhans  occurs  ;  these  cells  spread  out  over  the 
adjacent  surface  of  the  decidua  for  some  distance,  and  also 
penetrate   it   to    some   extent,    lying   among   the   decidual 


40  NORMAL   PREGNANCY 

cells  proper  (Fig.  26).  In  this  way  the  villus  and  the  decidua 
become  firmly  welded  together  by  a  vital  process  of  growth. 
Many  viUi  can  be  found  deeply  imbedded  in  this  manner  ; 
others  are  attached  merely  by  their  tips.  (6)  At  the  placen- 
tal margin  where  the  three  parts  of  the  decidua  are  united, 
the  membrane  is  of  great  thickness  and  strength  ;  from  this 
thickened  portion  a  process  can  be  traced  running  inwards  for 
a  distance  of  1  to  2  inches  beneath  the  chorionic  membrane 
(Fig.  28),  thus  adding  greatly  to  the  area  and  strength  of 
the  union  between  maternal  and  foetal  structures.  This 
portion  is  termed  the  suh-chorionic  decidua  ;  it  will  be  seen 
that  it  limits  circumferentially  the  general  system  of  the 
intervillous  spaces. 

(3)  The  development  of  the  maternal  circulation  through 
the  placenta  has  not  yet  been  traced  in  detail ;  great  contro- 
versy has  raged  in  the  past  upon  the  origin  of  the  intervillous 
spaces,  into  which  we  need  not  enter,  as  this  controversy  is 
now  dead.  The  ova  of  Peters  and  Leopold  show  us  the 
beginnings  of  these  spaces,  and  no  great  stretch  of  the  imagi- 
nation is  required  to  carry  the  student  from  the  reticulated 
trophoblast  of  the  second  week  to  the  chorio -decidual 
space  of  the  third,  and  from  the  latter  to  the  intervillous 
spaces  of  the  placenta  itself.  The  intervillous  spaces  are, 
of  course,  progressively  developed  from  the  meshes  of  the 
trophoblast.  In  an  ovum  of  two  weeks'  development  small 
mesoblastic  processes  may  be  seen  penetrating  the  tropho- 
blast buds  for  a  short  distance.  Later  on  these  buds  may 
be  seen  to  have  increased  greatly  in  length  ;  later  stiU  they 
become  branched,  and  are  then  vascularised  by  vessels 
which  grow  into  them  from  the  chorion.  These  are  fully 
formed  chorionic  viUi  ;  they  are  separated  from  one  another 
by  a  system  of  inter- communicating  spaces  which  are  the 
direct  derivatives  of  the  meshes  of  the  trophoblast.  During 
the  development  and  growth  of  the  placenta  large  maternal 
vessels  become  laid  open,  so  as  to  communicate  with  these 
spaces,  and  the  active  agents  in  the  production  of  this  impor- 
tant change  are  the  chorionic  vilh.  The  destructive  influence 
exerted  upon  maternal  tissues  by  the  young  chorionic  epi- 
thelium has  been  referred  to  ;  evidences  of  penetration  of 
the  walls  of  maternal  vessels  by  syncytial  buds  and  processes 
are  abundant  in  the  developing  placenta,  where  aU  stages 


PLACENTAL   CIRCULATION  41 

of  the  process  may  be  traced  in  tissue  cut  into  serial  sections. 
The  vessels  thus  penetrated  are  probably  merely  the  dilated 
capillaries  or  '  sinuses/  which  have  been  described  as 
occurring  in  the  endometrium  of  menstruation  and  in  the 
decidua — i.e.  they  are  vessels  the  walls  of  which  consist 
merely  of  an  endothelial  coat,  and  which  therefore  offer  but 
a  feeble  resistance  to  the  proteolytic  action  of  the  chorionic 
epithelium.  After  having  been  thus  laid  open  they  lose 
their  endothelial  lining.  It  is  often  difficult  to  distinguish 
afferent  from  efferent  maternal  channels,  since  both  arise 
from  dilated  capillaries.  A  minor  result  of  proteolytic 
action  is  that  the  surface  of  the  decidua  basalis  becomes 
irregularly  excavated  and  presents  a  series  of  elevations 
and  depressions.  Where  villi  are  not  in  actual  contact 
with  the  decidua  a  thick  layer  of  fibrin  is  deposited  upon  it 
from  the  maternal  blood.  Many  maternal  vessels  can  be 
seen  opening  into  the  intervillous  spaces  on  the  floor  of  the 
decidua  (Fig.  27).  The  maternal  circulation  through  the 
placenta  is  probably  slow.  The  coiling  course  of  the  uterine 
arteries  in  the  muscular  coat  diminishes  the  force  of  the 
current  entering  the  placenta  ;  the  outflow  from  the  inter- 
villous spaces  is  perhaps  aided  by  the  intermittent  uterine 
contractions  characteristic  of  pregnancy,  which  may  have 
the  effect  of  aspirating  the  blood  into  the  veins.  Towards 
the  middle  of  pregnancy  the  sub -placental  sinuses  assume 
very  large  proportions,  and  their  closure  after  the  placenta 
has  been  shed  is  a  matter  of  vital  importance  to  the  life  of 
the  mother. 

Concurrently  with  the  formation  of  the  placenta,  the  villi 
of  the  extra-placental  chorion  atrophy  and  become  function- 
less,  converting  that  portion  into  a  smooth  membrane  to 
which  the  name  chorion  Iceve  is  applied  ;  the  placental 
chorion  is  termed  the  chorion  frondosum.  Chorion  Iseve  and 
decidua  capsularis  are  not  united  by  intergrowth,  as  are 
chorion  frondosum  and  decidua  basalis. 

As  these  changes  progress  the  chorio-decidual  space  out- 
side the  placental  area  becomes  obliterated  by  the  pressure  of 
the  growing  ovum  ;  atrophied  villi  surrounded  by  deposits  of 
fibrin  may  always  be  found  in  the  membranes  at  term  if 
looked  for  under  a  microscope  (Fig.  29).  The  placental 
area  grows  very  rapidly  during  the  first  few  weeks  of  its 


42 


NORMAL   PREGNANCY 


formation,  until  at  the  end  of  the  third  month,  when  the 
ovum  fills  the  uterine  cavity,  it  occupies  about  one-fourth 
to  one-fifth  of  the  total  area  of  the  surface  of  the  uterine  walls. 
Afterwards  it  grows  pari  passu  with  the  uterus,  and  the  same 
proportion  is  preserved  up  to  term. 

When  the  ovum  grows  large  enough  to  fill  the  uterine 


Pig.  29.- — -Section  througli  the  Membranes  near  tlie  placental  margin. 
The  atrophied  vilU  show  remains  of  their  epithelial  covering. 

cavity  completely — i.e.  about  the  end  of  the  third  month 
— ^the  decidua  capsularis  becomes  apposed  to  the  decidua 
vera,  and  at  term  these  two  portions  of  the  maternal  mem- 
branes are  inseparable.  Up  to  the  end  of  the  third  month  a 
space  exists  in  the  uterine  cavity  below  the  ovum,  bounded 
above  by  the  decidua  capsularis,  laterally  by  the  decidua 
vera,  and  below  by  the  os  internum  ;  it  is  called  the  decidual 


PLACENTAL   CIRCULATION  43 

s'pace  (Figs.  14  and  15).  When  the  two  portions  of  the  decidua 
become  apposed,  the  decidual  space  is  obhterated.  At  term 
the  decidua  capsularis  has  undergone  extensive  atrophy  from 
pressure,  and  the  same  change,  but  less  advanced,  is  observed 
in  the  decidua  vera.  This  is  of  importance  in  relation  to  the 
process  of  shedding  the  placenta. 

Upon  the  maintenance  of  the  relations  just  described 
between  the  foetal  and  maternal  elements  of  the  placenta  the 
nutrition  of  the  foetus  in  utero  entirely  depends.  After  the 
formation  of  the  firm  chorio-decidual  attachments,  accidental 
separation  of  the  two  is  not  so  readily  brought  about  as  at 
earlier  periods  ;  hence  the  diminished  liability  to  abortion 
after  the  third  month. 

We  know  very  little  about  the  details  of  the  interchanges 
between  the  foetal  and  maternal  blood-currents.  Particles 
of  finely  divided  insoluble  solid  matter  artificially  introduced 
into  the  maternal  circulation  in  animals,  cannot  pass  through 
the  placenta  to  the  foetus  ;  but  micro-organisms  are  able  to 
do  so  in  disease.  It  has  been  shown  by  Kiiss  that  the 
following  bacteria  may  be  transmitted  from  mother  to  foetus 
through  the  placenta  :  tubercle  bacillus,  bacillus  of  anthrax, 
diphtheria  and  glanders,  the  pneumococcus,  streptococcus, 
and  meningococcus.  Further,  it  has  been  shown  by  experi- 
ment that  the  placenta  possesses  a  certain  selective  power  in 
transmission,  for  chemical  substances  in  solution  are  not  all 
transmitted,  and  those  which  pass  the  placenta  do  so  at 
unequal  rates.  Further,  the  selective  action  of  the  placenta 
is  modified  when  maternal  disease  is  present.  From  com- 
parative analyses  of  the  foetal  blood  flowing  to  and  leaving 
the  placenta,  we  know  that  it  gives  up  carbonic  acid  and 
absorbs  oxygen  in  transit.  The  placenta  is  therefore  the 
respiratory  organ  of  the  foetus,  but  we  know  little  or  nothing 
of  the  other  nutritional  interchanges  effected  by  the  placen- 
tal circulation.  Osmosis  can,  of  course,  readily  take  place 
between  the  foetal  blood  in  the  vessels  of  the  villi  and  the 
maternal  blood  in  the  intervillous  spaces,  and  it  is  easy  to 
understand  how  soluble  solid  and  gaseous  substances  can 
pass  freely  from  mother  to  foetus,  or  the  reverse.  Glycogen 
and  fat  are  present  in  the  placenta  in  considerable  amount, 
but  whether  these  substances  are  derived  directly  from 
maternal  sources,  or  whether  they  are  produced  by  the  foetal 


44  NORMAL  PREGNANCY 

liver  or  other  foetal  organs  and  deposited  in  the  placenta  from 
the  foetal  blood,  is  at  present  unknown. 

The  presence  of  a  proteolytic  ferment  and  of  other 
enzymes  in  the  foetal  portion  of  the  placenta  has  been  demon- 
strated bj^  physiological  experiment,  but  nothing  is  definitely 
known  of  theii^  origin  or  of  their  functions  in  regard  to 
foetal  metabohsm. 

The  Placenta  at  Term. — When  shed  from  its  uterine 
attachments  the  placenta  is  an  oval  or  circular  fiat  cake  or 
disc  measuring  6  to  8  inches  (15  to  20  cm.)  in  diameter, 
f  to  1  inch  (2  to  2^  cm.)  in  depth  at  the  centre,  which  is 
the  thickest  part,  and  w^eighing  about  sixteen  ounces.  The 
margin  is  thinner  and  firmer  than  the  centre,  and  passes 
abruptly  into  the  chorion  Iseve.  The  foetal  surface  is  covered 
with  a  thin  smooth  membrane — the  amnion,  which  can  be 
readily  stripped  up  to  the  insertion  of  the  umbilical  cord. 
The  surface  of  the  chorion  thus  exposed  is  also  smooth  in 
appearance,  and  running  over  it  are  seen  the  large  superficial 
branches  of  the  umbihcal  vessels.  The  arteries  run  irregu- 
larly outwards,  but  never  quite  reach  the  margin  in  a  normal 
placenta  (Fig.  30)  ;  the  veins  accompany  and  often  cross 
them.  If  the  foetal  surface  is  now  incised,  the  chorionic 
membrane  is  seen  to  be  about  one  line  in  thickness,  and  from 
its  deep  surface  springs  the  mass  of  spongy  tissue  repre- 
senting the  villi.  The  uterine  surface  (Fig.  31)  contrasts 
strongly  with  this.  It  is  of  a  dull  red  colour,  and  is  divided 
by  sulci  into  a  number  of  irregularly  quadrilateral  areas 
termed  the  cotyledons.  No  vessels  are  visible  upon  it.  On 
close  inspection  it  can  be  seen  to  be  covered  with  a  thin 
greyish  mottled  membrane  which  represents  the  shed  por- 
tion of  the  decidua  basahs  ;  in  parts  this  is  incomplete, 
exposing  the  deep  red  spongy  tissue  beneath,  and  often  it 
feels  gritty  to  the  touch  from  the  presence  of  minute  areas 
of  calcareous  degeneration.  In  some  instances,  areas  of 
calcareous  degeneration  are  found  large  enough  to  be  visible 
to  the  naked  eye  ;  these  are  generally  found  near  the  centre 
of  the  placenta.  Around  the  margin  runs  a  large  venous 
channel  called  the  circular  sinus,  which  returns  some  of  the 
maternal  blood  from  the  intervillous  spaces  ;  it  seldom 
completely  surrounds  the  placenta.  If  the  placenta  is 
incised,  a  great  deal  of  dark  blood  slowly  runs  away  from  it, 


THE   PLACENTA 


45 


and  if  a  stream  of  water  is  turned  upon  the  cut  surface  the 
intervillous  spaces  will  be  washed  out  and  the  arborescent 
villi  appear  as  a  dense  reticulum  of  greyish  threads.     The 


Fig.  30. — Human  Placenta,  foetal  surface ;  the  inner  thin  membrane 
is  the  amnion,  the  outer  thick  one  is  the  chorion. 


placenta  is  usually  attached  to  the  upper  part  of  the  body 
of  the  uterus,  including  the  fundus,  and,  with  about  equal 
frequency,  to  the  adjacent  anterior  or  posterior  wall. 

Clear  evidence  of  extensive  degeneration  is  to  be  found 
in  the  placenta  at  term.     It  must  be  remembered  that  the 


46 


NORMAL   PREGNANCY 


placenta  is  a  caducous  structure  which,  after  serving  its 
temporary  purpose,  is  cast  ofE  by  the  organism.  Degeneration 
is  the  necessary  prehminary  of  shedding,  and  merely 
indicates  a  progressive  diminution  of  vitahty  towards  the 
close  of  the  period  of  its  existence.  These  degenerative 
changes  are  chiefly  of  importance  because  of  the  necessity 
of  distinguishing  them  from  true  morbid  processes.     Both 


Fig.  31. — Human  Placenta,  uterine  or  maternal  surface, 
patches  are  areas  of  calcareous  degeneration. 


The  white 


the  foetal  and  maternal  elements  of  the  placenta  are  affected. 
The  initial  change  consists  in  the  occlusion  of  considerable 
tracts  of  the  middle-sized  divisions  of  the  umbilical  arteries 
by  a  process  of  obliterating  endarteritis  ;  it  may  be  found 
as  early  as  the  seventh  month  of  pregnancy,  and  it  slowly 
progresses.  This  causes  a  diminution  in  the  blood  supply 
of  the  villi  fed  by  the  affected  arterioles,  which  results  in 
their   gradual    atrophy    and    degeneration  ;     this    again   is 


THE   PLACENTA  47 

accompanied  by  the  extensive  deposition  of  fibrin  from  the 
maternal  blood  upon  the  chorionic  epithelium,  so  that  the 
neighbouring  villi  meet  and  the  intervillous  spaces  of  the 
affected  area  thus  become  obliterated.  In  this  manner 
solid  patches  are  formed  among  the  spongy  placental 
tissues,  in  which  the  villi  are  functionless,  for  the  foetal 
circulation  has  been  arrested  by  obliterating  endarteritis, 
while  the  maternal  circulation  has  been  destroyed  by 
blocking  of  the  intervillous  spaces  with  fibrin.  These  patches 
are  termed  'placental  infarcts  ;  they  occur  as  firm  yellowish- 
white  well-defined  areas,  varying  in  size,  under  normal  con- 
ditions, from  that  of  a  millet  seed  to  that  of  a  filbert.  They 
are  most  numerous  on  the  uterine  surface  and  on  the  marginal 
cotyledons.  The  superficial  layers  of  the  decidua  basalis 
undergo  a  form  of  coagulation  necrosis,  and  upon  the 
necrosed  areas  laminated  deposits  of  fibrin  from  the  maternal 
blood  are  formed.  In  addition,  extensive  thrombosis  occurs 
in  the  sub-placental  sinuses  during  the  later  months  of  preg- 
nancy, the  cause  of  which  is  not  well  understood,  but  which 
certainly  interferes  to  some  extent  with  the  freedom  of  the 
maternal  circulation. 

From  about  the  fifth  month  onwards  the  chorionic  epi- 
thelium consists  of  only  one  layer — the  syncytium  ;  the 
layer  of  Langhans  has  disappeared.  The  syncytium  is  also 
much  less  active  in  the  later  than  in  the  earlier  months, 
throwing  out  comparatively  few  buds  and  processes  ;  and  as 
term  approaches  this  layer  becomes  atrophied  and  incom- 
plete (Fig.  24). 

It  is  possible  that  these  degenerative  changes  limit  the 
duration  of  pregnancy,  and  participate  in  causing  the  onset 
of  labour  by  rendering  the  placenta  incapable  of  providing 
for  the  continually  increasing  nutritional  requirements  of 
the  foetus. 

Amnion,  Umbilical  Cord,  and  Foetus 

Amnion. — This  membrane  consists  of  an  outer  layer  of 
mesoblast  and  an  inner  layer  of  epiblast.  In  the  human 
ovum  it  is  probably  from  the  first  a  closed  sac,  and  in  the 
earliest  ova  it  is  seen  to  be  very  much  smaller  than  the 
chorion  and  separated  from  it  by  a  considerable  thickness 


48 


NORMAL   PREGNANCY 


of  mesoblastic  tissue.     These  relative  proportions  are  pre- 
served for  some  weeks,  and  so  slowly  does  the  fluid  accumu- 


FlG.  32. — Complete  Ovum  from  the  fourth,  or  fifth  -week,  magnified. 
The  foetus  is  closely  invested  by  the  amnion,  and  is  attached  by 
the  ventral  stalk  to  the  wall  of  the  chorionic  vesicle.  (Quain's 
■Anatomy.) 

late  in  the  amnion  that  it  does  not  grow  large  enough  to 
come  into  contact  with  the  chorion  until  the  third  month 
(Figs.  33  and  34). 


THE  AMNION 


49 


Until  the  body  of  the  embryo  has  been  clearly  defined 
the  amnion  covers  only  its  dorsal  surface ;  gradually, 
however,  its  line  of  origin  advances  over  the  ventral  surface 
to  converge  upon  the  umbilical  cord.  Ultimately  amnion 
and  chorion  come  in  loose  contact  by  their  mesoblastic 
surfaces,  but  no  vital  union  takes  place  between  them.  The 
fully  formed  amnion  consists  of  a  single  layer  of  cubical  or 
low  columnar  epithelium  resting  upon  a  stratum  of  loose 
connective  tissue.     As  pregnancy  advances  the  epithelium 


Fig.  33. • — Complete  Ovum  from  about  the  nintli  week.  Note  the  large 
size  of  the  chorionic  vesicle,  and  the  small  size  of  the  amniotic  sac, 
which  is  full  of  fluid.     (Quain's  Anatomy.) 

becomes  flatter.  The  amnion  is  firmly  united  to  the  um- 
bilical cord  at  its  point  of  insertion  into  the  placenta,  so 
that  it  cannot  be  stripped  off  the  cord,  although  it  is  readily 
separable  from  both  the  placental  and  extra-placental 
chorion  {chorion  frondosum  and  chorion  loeve). 

At  an  early  period  fluid  (the  liquor  amnii)  appears  within 
the  amnion,  separating  it  from  the  dorsal  surface  of  the 
embryo .  This  gradually  increases  in  quantity  as  development 
advances,  until  at  term  it  amounts  on  an  average  to  one  or 
two  pints  ;   variations  from  ten  to  fifty  ounces  are,  however, 

E.M.  4 


50 


NORMAL  PREGNANCY 


not  uncommon  under  normal  conditions.  At  term  it  is  a 
clear  pale  fluid  of  low  specific  gravity,  and  its  composition, 
according  to  Hoppe-Seyler,  is  as  follows  : 


Water      . 
Albumen 
Inorganic  salts 
Extractives     . 


98-41  per  cent. 
0-19 
0-59 
0-81 


U.V..— /— 


Fig.  34. — Umbilical  Cord  near  Fcetal  End,  X5|, 

U.A. — Umbilical  Arteries.         U.S. — Remnant  of  Allantois 


(Whitridge  WiUiams.) 

U.  v.— Umbilical  Vein. 


The  amount  of  albumen  present  in  the  early  months  is  much 
higher  than  this,  and  may  reach  10  per  cent.  The  most 
important  extractive  is  urea,  which  is  present  in  traces  from 
the  sixth  week  onwards.  Various  matters  in  suspension  are 
also  found,  such  as  lanugo  hairs,  epidermal  scales,  cells 
derived  from  the  amniotic  epithelium,  and  particles  of  vernix 
caseosa  detached  from  the  skin  of  the  foetus.  Glucose  may 
be  found  in  cases  of  maternal  diabetes.  The  function  of 
the  amniotic  fluid  is  mainly  protective.  It  assists  in  main- 
taining an  even  temperature,  acts  as  a  buffer  against  external 
injuries,  equalises  pressure,  allows  free  movements  of  the 


UMBILICAL   CORD 


51 


Umbilical   vein 
distended,  with  Mood 


Umbilical  arteries 
retracted 


foetus,  and  flushes  the  passages  from  within  with  a  sterile 
fluid  during  labour.  Nutritive  value  has  been  claimed  for 
it  on  the  ground  that  it  is  swallowed  by  the  foetus  during  the 
latter  months  of  gestation.  Certainly  lanugo  and  epidermal 
scales  are  not  uncommonly  found  in  meconium,  and  there 
is  no  doubt  that  they  have  entered  the  alimentary  canal 
by  being  swallowed  with  liquor  amnii ;  sometimes  also 
balls  of  fine  lanugo  hairs  have  been  found  in  the  stomach 
of  a  dead  foetus.  It  is  possible,  therefore,  that  fluid  obtained 
by  swallowing  liquor  amnii  may  be  of  use  in  the  general 
metabolism  of  the  foetus. 

Umbilical  Cord. — This  structure  connects  the  body  of 
the  foetus  with  the  pla- 
centa. Its  earhest  appear- 
ance in  the  human  ovum 
is  shown  in  the  specimens 
of  Spec  (Figs.  18  and  19), 
where  a  band  of  the 
mesoblastic  tissue  is  seen 
uniting  the  embryonic 
area,  with  its  amnion  and 
umbilical  vesicle,  to  the 
chorion.  This  band  was 
previously  described  by 
His,  who  termed  it  the 
ventral  stalk.  Along  this 
stalk  pass  the  foetal  ves- 
sels which  vascularise 
the  growing  chorion  ;  they  are  branches  of  the  posterior 
end  of  the  primitive  abdominal  aorta.  Later  the  allantois 
also  grows  into  it  ;  this  structure  is  an  outgrowth  from  the 
hinder  end  of  the  primitive  gut,  and  in  lower  mammals  it 
is  larger,  and  plays  a  much  more  important  part,  than  in 
man.  Sometimes  in  the  human  ovum  the  allantois  does 
not  extend  as  far  as  the  chorion  at  all  ;  and  according  to 
His  the  ventral  stalk  may  be  vascularised  before  its  appear- 
ance, so  that  it  is  evident  that  the  part  which  it  plays  in 
the  development  of  the  umbilical  cord  is  a  secondary  one. 
Later  on  the  entodermic  or  umbilical  vesicle,  with  its  om- 
phalo-mesenteric  (vitelline)  duct,  also  fuses  with  the  ven- 
tral stalk,  so  that  the  umbilical   cord  when  fully  formed 

4—2 


Fig.  35.— The  Umbilical  Cord  at  Ten 

A.     Transverse  section  showing  vessels. 
B.     A  portion  showing  torsion. 


52 


NORMAL  PREGNANCY 


tv^ 


consists  developmentally  of  the  following  component  parts  : 
(1)  the  ventral  stalk;  (2)  the  umbihcal  blood-vessels  from 
the  primitive  aorta ;  (3)  the  allantois  ;  (4)  the  umbilical 
vesicle  with  its  vitelline  duct. 

In  an  early  embryo  (Figs.  32  and  39)  the  cord  is  short 
and  very  thick  ;  its  surface  is  ridged, 
and  it  is  attached  to  the  ventral  sur- 
face close  to  the  caudal  extremity. 
About  the  third  month  of  gestation 
four  vessels  are  found  in  the  cord — 
two  arteries  and  two  veins  ;  the  latter 
afterwards  fuse  to  form  a  single 
vessel,  so  that  at  term  there  are  two 
arteries  and  one  vein.  Traces  of  the 
allantois,  in  the  form  of  a  small  canal 
lined  by  cubical  epitheUum,  may  be 
found  in  the  foetal  end  of  the  cord 
up  to  term  (Fig.  34).  The  umbihcal 
vesicle  is  seen  in  ova  of  about  the 
second  month  to  be  of  considerable 
size,  and  attached  by  a  long  pedicle 
to  the  umbihcal  cord  near  its  ventral 
attachment.  Later  on  it  disappears, 
but  it  is  stated  that  a  trace  of 
it  may  sometimes  be  found  at  term 
in  the  form  of  a  minute  yellowish 
body  at  the  placental  insertion  of  the 
cord.  The  coelom  is  also  prolonged 
into  the  cord,  and  coils  of  small  m- 
testine  may  be  found  at  the  foetal  end 
in  the  early  months  of  gestation,  and 
this  condition  may  persist  to  term, 
giving  rise  to  a  congenital  ventral 
hernia  or  exomphalos. 
At  term,  the  cord  varies  in  length  from  5  to  60  inches 
(12  cm.  to  150  cm.),  the  average  being  from  18  to  24  inches 
(45  cm.  to  60  cm.).  The  vessels  are  always  twisted,  the 
arteries  usually  encircling  the  vein  from  left  to  right ;  this 
torsion  is  evident  as  early  as  the  thh'd  month,  but  the  cause 
of  it  is  unknown  (Fig.  41).  The  substance  of  the  cord  is 
composed  of  a  special  form  of  embryonic  connective  tissue, 


Pig.  36.— Umbilical 

Cord  -with  True  Knot. 

(Charing  Cross 

Hospital  Museum.) 


UMBILICAL  CORD 


53 


which  has  been  called  Wharton's  Jelly.  It  consists  of  small 
stellate  cells  with  long  processes  ;  anastomosing  with  others, 
the  processes  form  a  wide  network,  the  meshes  of  which  are 


\ 


^ 


la 


EiG.  31. — Wharton's  Jelly,  showing  the  Stellate  Cells. 
(Galabin  and  Blacker.) 

filled  with  gelatinous  material  (Fig.  37).  This  connective 
tissue  is  irregularly  disposed  round  the  vessels,  giving  rise,  in 
places,  to  protuberances  termed  false  knots,  which  at  times, 
but  not  always,  contain   a  loop  of  vessels.     Sometimes  a 


Fig.  38.— Epithelium  of  Umbilical  Cord.     (Whitridge  Williams.) 

true  knot  is  formed  by  the  foetus  slipping  through  a  loop 
of  a  very  long  cord  in  utero  (Fig.  36).  This  does  not  neces- 
sarily arrest  the  circulation  through  the  cord.  The  epithelial 
covering  of  the  cord  consists  at  term  of  stratified  cubical 
cells,    resembling    the    foetal    epidermis    (Fig.    38).      It    is 


54 


NORMAL   PREGNANCY 


generally  believed  that  these  cells  are  formed  from  a  pro- 
longation of  the  foetal  skin  over  the  umbilical  cord  and 
are  not  develoj)ed  from  the  amnion. 

The  cord  is  usually  attached  to  the  centre  of  the  placenta 
{central  insertion)  ;  it  may,  however,  be  placed  nearer  the 
margin  than  the  centre  [excentric  insertion)  or  upon  the  edge 
{battledore  insertion),  or  it  may  be  inserted  upon  the  mem- 
branes outside  the  placenta  {velamentous  insertion)  (see 
Fig.  71).     The  foetal  insertion  of  the  cord  is  not  subject  to 


Pig.  39. — Embryo  9-1  mm.  in  length,  of  thirty-one  to  thirty-four  days' 
development.     (His,  from  Quain's  Anatomy.) 

variation.  It  will  be  noted  that  while  its  precursor,  the 
ventral  stalk,  is  attached  to  the  caudal  extremity,  as  the 
coelom  closes  and  the  umbilical  vesicle  atrophies,  the  point 
of  attachment  is  carried  forward  until  at  the  fourth  month 
it  reaches  the  centre  of  the  body  of  the  foetus. 

Foetus. — During  the  first  six  weeks  of  its  development  the 
human  embryo  is  indistinguishable,  except  by  an  expert 
embryologist,  from  that  of  other  mammals.  About  the  end 
of  the  second  month  it  acquires  definite  characteristics  which 
serve  to  distinguish  it  from  others.     It  is  usual  to  speak  of  the 


THE   FGETUS 


55 


embryo  during  the  first  two  months,  and  the  foetus  later  than 
that  period. 

In  the  earliest  human  ovum  which  has  been  carefully 
described,  viz.,  that  of  Bryce  and  Teacher  (Fig.  10),  the  em- 
bryo is  represented  by  two  minute  vesicles,  amniotic  and  ento- 
dermic,  and  a  thickened  layer  of  epiblast,  the  embryonic 
epiblast.  Not  until  the  end  of  the  fourth  week  has  been 
reached  is  the  body  of  the  embryo  at  all  clearly  defined,  and 
at  this  'stage  it  j  mea- 
sures from  7  to  10mm.  - 
in  length  (Fig.  39).  It 
is  markedly  flexed, 
and  the  head  is  nearly 
as  large  as  the  remain- 
der of  the  body  ;  the 
branchial  arches  are 
unclosed,  the  limbs 
appear  as  buds,  there 
is  a  large  umbilical 
vesicle,  the  umbilical 
cord  is  inserted  close 
to  the  caudal  ex- 
tremity, which  is  long 
and  pointed,  and  there 
is  nothing  to  distin- 
guish it  from  the  em- 
bryo of  other  mam- 
mals, such  as  the 
rabbit. 

During  the  second 
month  distinctively 
human    features     are 

developed,  and  by  the  eighth  or  ninth  week  it  measures 
about  30  mm.,  and  is  not  so  markedly  flexed  (Fig.  41).  The 
face  has  become  closed  in  by  the  growth  of  the  maxillary 
and  mandibular  processes,  and  the  eyes  and  ears  have 
assumed  their  characteristic  form  ;  the  limbs  have  become 
divided  into  their  segments  and  the  digits  are  well  formed. 
The  caudal  extremity  or  tail  has  become  reduced  to  a  minute 
tubercle. 

At  the  end  of  the  third  month  the  foetus  measures  7-5  to 


Fk 


.  40. — -Embryo  15"5'  mm.  in  length.,  of 
about  five  to  six  weeks'  development. 
(Bryce,  from  Quain's  Anatomy.) 


56 


NORMAL  PREGNANCY 


9  cm.  (3-3|^  inches)  ;  the  umbihcal  cord  equals  it  in  length, 
and  its  vessels  have  become  twisted  ;  although  the  external 
sexual  organs  are  undifferentiated,  the  sex  may  be  established 
by  examination  of  the  internal  organs. 

During  the  fourth  month  the  muscles  become  developed 
and  spontaneous  movements  are  made. 

The  progress  of  the  foetus  in  length  and  weight  during  the 


Fig.  41. — Embryo  30  mm.  in  length,  of  about  nine  weeks' 
development.     (Bryce,  from  Quain's  Anatomy.) 

succeeding  months  of  gestation  is  as  shown  in  the  table 
opposite.  It  will  be  seen  that  the  rate  of  growth  of  the  foetus 
is  not  only  very  irregular  from  one  month  to  another,  but 
subject  to  considerable  variations.  A  simple  method  of 
determining  the  period  of  development  of  the  foetus  with 
sufficient  accuracy  for  clinical  purposes  during  the  second 
five  months  is  found  by  multiplying  the  number  of  the  month 


THE  FCETUS 


57 


by   five.      Thus    the    length   at   the   end    of   the   seventh 
month  7  X  5  =  35  cm.  (14  inches). 


Period. 

Length. 

Weight. 

4th  month  (lunar) 

10  to  17  cm.  (  4    to    e^in.) 

ilb. 

5th       ,, 

18  to  27    ,,    (  7    to  lOJ  „  ) 
28  to  34    „    (11    to  131  ,^  ) 

4  ,- 

6th       „ 

14  „ 

7th       ,, 

35  to  38    ,,    (14    to  15     ,,  ) 

2*  „ 

8th       , 

39  to  41    ■„    (15*  to  16*  „  ) 

34   „ 

9th 

42  to  44    ,,    (17    to  174  ..  ) 

4i   „ 

10th       ,,           „ 

50  to  53     „     (20    to  21     „  ) 

7  to  74  „ 

At  the  end  of  the  seventh  lunar  month  (28th  week)  the 
foetus  becomes  capable  of  surviving  when  born — i.e.  it 
becomes  viable  ;  its  chances  of  survival  at  this  period  are, 
however,  very  small.  A  twenty-eight  weeks'  foetus  has  the 
skin  of  a  deep,  dull  red  colour,  there  is  hair  on  the  scalp,  and 
a  little  sebaceous  secretion  has  been  produced.  In  the  male 
the  testicles  have  descended  into  the  scrotum. 

At  the  thirty-sixth  week  the  foetus  has  increased  greatly 
in  bulk,  but  not  so  markedly  in  length.  The  colour  of  the 
skin  is  a  brighter  pink  and  light  delicate  hair  (lanugo) 
covers  the  whole  of  the  body  except  the  scalp,  where  long 
dark  hair  is  seen.  The  general  surface  of  the  body  is  covered 
with  a  deposit  of  sebaceous  matter  {vernix  caseosa),  and  a 
well  defined  layer  of  subcutaneous  fat  has  appeared,  giving 
rotundity  to  the  outlines  of  the  trunk  and  limbs.  The 
abdomen  is  still  relatively  protuberant,  especially  in  the 
upper  part. 

During  the  last  four  weeks  the  chief  change  is  a  great 
gain  in  length  and  weight  and  increase  in  potential  activity. 
The  free  and  energetic  movements  which  the  foetus  makes 
habitually  during  this  period  no  doubt  contribute  to  its 
muscular  development. 

The  Mature  Foetus. — Though  subject  to  considerable 
variations,  the  average  length  of  the  foetus  at  term  is  about 
50  cm.  (20  inches)  and  the  average  weight  7  to  7^  pounds. 
Males  are  usually  rather  heavier  than  females.  Weight  is 
much  more  variable  than  length,  for  from  various  causes  a 
mature  foetus  may  weigh  much  less  than  the  average,  while, 
from  disease,  a  premature  foetus  may  equal  it  in  weight. 


58  NORMAL   PREGNANCY 

Healthy  mature  infants  may  weigh  only  5  to  5^  pounds, 
but  any  weight  below  this  is  probably  to  be  attributed  to 
pre-maturity,  to  hereditary  sj^hilitic  taint,  or  other  maternal 
disorder.  A  foetus  weighing  over  10  pounds  is  not  rare  ; 
a  weight  of  over  12  pounds  is,  however,  very  uncommon  and 
is  usually  accounted  for  by  post-maturity^ — i.e.  undue  pro- 
longation of  the  period  of  gestation.  The  general  differences 
between  a  premature  and  a  mature  foetus  may  be  tabulated 
as  follows  : 

Seven  months'  Fatus.  |  Mature  Foetus. 

1.  Skin  lax,  wrinkled,  dull  red  in       Skin  smooth.,  plump,  pink,  covered 


colour,  little  vernix  caseosa. 
2.  Subcutaneous  fat  scanty. 
'6.  Hair  on  scalp  short. 

4.  Lanugo  present  over  whole  body. 


with,  vernix  caseosa. 
Subcutaneous  fat  abundant. 
Abundant  dark  hair  on  scalp,  1  to 

\\  inch  long. 
Lanugo  absent  from  most  situations. 

5.  Short  nails  on  fingers  and  toes,     j    Xails  project  beyond  finger  tips. 

6.  Skull  sutures  open.  Skull  sutures  closed  (i.e.  bones  in 

contact)  except  at  fontanelles. 

7.  Moves    and    cries   feebly   when      Moves  and  cries  vigorously  when 

born.  I  born. 

The  Foetal  Circulation. — The  umbilical  vein,  which  brings 
purified  arterial  blood  from  the  placenta,  enters  the  trunk  at 
the  umbihcus  and  runs  beneath  the  anterior  abdominal  wall 
to  reach  the  lower  surface  of  the  Hver  (Fig.  42,  vu.).  Here  it 
gives  off  branches  to  the  left  lobe,  the  lobus  quadratus  and 
lobus  Spigelii,  which  thus  receive  a  direct  supply  of  pure 
blood  from  the  placenta.  It  then  gives  off  another  branch 
which  joins  the  portal  vein  (vp.)  as  the  latter  is  about  to  enter 
the  right  lobe  ;  as  the  portal  vein  brings  impure  blood  from 
the  alimentary  canal,  the  blood-supply  of  the  right  lobe  of 
the  liver  is  less  pure  than  that  of  the  other  lobes.  After 
giving  off  these  branches  to  the  hver,  the  umbilical  vein, 
now  reduced  in  size  and  called  the  ductos  venosus  (cZv.), enters 
the  inferior  vena  cava  {vci.).  Blood  which  has  passed  through 
the  liver  is  carried  by  the  hepatic  veins  {vh.)  to  the  same 
great  venous  trunk,  which  now  contains  a  mixed  stream 
consisting  of  pure  blood  from  the  ductus  venosus,  and  impure 
blood  coming  up  from  the  lower  extremities  through  the 
ihac  veins,  and  from  the  hver  through  the  hepatic  veins. 
The  blood  brought  up  to  the  heart  by  the  inferior  vena  cava 


FCETAL   CIRCULATION 


59 


■  ='Venous  blood,  from  head,  neck 
viscera,  and  extremities. 

'&  =  Arterial  blood  from 

placenta. 
Pii>=  Mixed  blood. 


Fig.  42. — Scheme  of  the  Foetal  Circulation.     (Edgar.) 

is,  however,  still,  comparatively  speaking,  pure,  for  the 
amount  of  impure  blood  carried  into  this  vessel  by  the 
hepatic  and  iliac  veins  (lower  extremities  and  pelvis)  is 
relatively  small. 


60  NORMAL   PREGNANCY 

The  inferior  vena  cava  enters  the  floor  of  the  right 
auricle,  and  the  blood-stream  is  immediately  directed  by 
the  Eustachian  valve  through  the  foramen  ovale  into  the  left 
auricle  ;  thence  it  flows  through  the  mitral  valve  into  the 
left  ventricle,  and  thence  into  the  aorta.  From  the  aorta 
branches  pass  to  the  head,  neck,  and  upper  extremities 
through  the  innominate,  left  carotid,  and  left  subclavian 
trunks  ;  excepting  the  liver,  these  parts  therefore  receive 
the  purest  supply  of  blood.  From  these  parts  the  venous 
blood  is  returned  to  the  right  auricle  by  the  superior  vena 
cava  (vcs.)  ;  thence  it  passes  through  the  tricuspid  valve  to 
the  right  ventricle.  There  are  therefore  two  blood-currents 
crossing  one  another  in  the  right  auricle,  and  it  is  believed 
that  they  are  completely  separated  from  one  another  by  the 
Eustachian  valve.  From  the  right  ventricle  the  blood 
passes  into  the  pulmonary  artery,  which,  after  giving  off 
branches  to  the  lungs,  passes  on,  as  the  ductus  arteriosus  {da.), 
to  join  the  thoracic  aorta  near  the  origin  of  the  left  sub- 
clavian artery.  The  abdominal  aorta  {ao.)  now  contains  a 
very  mixed  supply  of  blood  consisting  of  a  small  amount  of 
arterial  blood  from  the  placenta,  which  has  passed  from  the 
right  auricle  through  the  Eustachian  valve  to  the  left  side 
of  the  heart,  and  a  large  amount  of  venous  blood  from  the 
lower  extremities  and  pelvis  (iliac  veins),  liver  (hepatic  veins), 
and  head,  neck,  and  upper  extremities  (ductus  arteriosus). 
The  aorta  divides  into  the  two  iliac  arteries  ;  each  of  these 
in  turn  divides  into  (1)  a  hj^pogastric  or  umbilical  artery  (au.), 
giving  off  twigs  to  the  pelvis,  and  then  passing  into  the 
cord,  and  so  to  the  placenta,  and  (2)  an  external  iliac  branch 
running  to  the  lower  limbs.  '  The  curious  anomaly  is  thus 
presented  that  the  arterial  supply  of  the  lower  extremities  is 
derived  from  the  same  trunk  as  the  venous  blood  which  is 
carried  to  the  placenta  to  be  purified.  The  blood  carried  to 
the  placenta  by  the  umbilical  arteries  passes  through  the 
villi,  and  is  returned  in  a  purified  state  to  the  foetus  through 
the  umbihcal  vein  (vu.). 

Changes  in  the  Foetal  Circulation  at  Birth. — These  are 
due  to  two  causes  :  (1)  the  expansion  of  the  lungs  by  respira- 
tion ;  (2)  the  arrest  of  the  placental  circulation.'  The 
immediate  effect  of  respiration  is  to  divert  a  great  part  of 
the  blood  from  the  right  ventricle  to  the  lungs,  and  the 


FOETAL  CIRCULATION  61 

ductus  arteriosus  accordingly  becomes  greatly  contracted. 
The  immediate  effect  of  arresting  the  placental  circulation 
is  to  reduce  the  pressure  in  the  right  auricle  by  diminishing 
the  quantity  of  blood  entering  it  through  the  inferior  vena 
cava.  At  the  same  time  the  pressure  in  the  left  auricle 
is  raised  by  the  increased  amount  of  blood  returned  to  it 
from  the  lungs  ;  the  pressure  in  the  two  auricles  is  thus  more 
or  less  equalised,  the  flap  valve  of  the  foramen  ovale  closes, 
and  the  passage  of  blood  from  the  right  to  the  left  auricle 
is  arrested.  The  umbilical  vessels,  ductus  arteriosus,  and 
ductus  venosus  become  gradually  occluded  by  thrombosis, 
but  aU  may  persist  in  the  form  of  fibrous  cords  in  the  adult. 
The  transition  from  the  foetal  to  the  adult  type  of  circulation 
is  probably  completed  in  a  few  days. 

General  Physiology  of  the  Foetus. — The  placenta  subserves 
the  functions  of  respiration  and  nutrition,  and  through  it  the 
foetus  obtains  aU  the  oxygen  and  nutritive  materials  it 
requires.  We  know  practically  nothing  of  the  manner  in 
which  the  materials  absorbed  from  the  maternal  blood  are 
worked  up  into  the  foetal  tissues.  There  can  be  no  doubt 
that  large  quantities  of  fat,  for  example,  are  produced  in 
some  way  in  the  body  of  the  foetus,  for  FehUng  has  shown 
that  the  proportion  of  fat  increases  from  0'45  per  cent,  of 
the  body-weight  at  the  fourth  month  to  9-1  per  cent,  at  term. 
As  fat  is  a  non-diffusible  substfince  it  cannot  pass  through 
the  placenta,  and  therefore  must  be  elaborated  by  the 
foetal  organs  themselves. 

Attention  has  been  already  drawn  to  the  large  size  of  the 
foetal  liver  in  the  eai:ly  months,  and  to  the  remarkable 
arrangements  for  supplying  it  with  purified  blood.  At  the 
fourth  week  of  gestation  the  foetal  liver  has  attained  a 
predominant  size  among  the  abdominal  viscera  ;  during  the 
second  month  this  predominance  increases,  causing  pro- 
tuberance of  the  upper  abdomen.  In  the  later  months  it 
becomes  proportionately  smaller,  but  even  at  term  it  is 
unduly  large,  for  it  weighs  one-eighteenth  part  of  the  total 
body- weight  of  the  foetus,  while  the  proportion  in  the  adult 
is  one-thirtieth.  In  the  third  month  the  gall-bladder  con- 
tains a  yellow  fluid  in  which  bile  salts  and  acids  can  be 
detected,  and  which  is  therefore  a  true  biliary  secretion. 
Bile  pigment  appears  later  ;    but  glycogen  and  urea,  both 


62  NORMAL   PREGNANCY 

products  of  hepatic  activity,  are  also  present  in  the  fostal 
tissues  at  an  early  period  of  development.  There  can  be 
very  little  doubt  that  the  Hver  plays  an  important  rdle  in 
foetal  physiology,  which  may  perhaps  be  as  much  construc- 
tive as  excretorj^. 

The  chief  excretory  organs — the  kidneys  and  the  skin — 
are  also  functionally  active  in  the  foetus.  We  do  not  know 
the  precise  period  at  which  the  kidneys  begin  to  secrete 
urine,  but  during  the  last  two  months  of  development  the 
bladder  usually  contains  a  httle  clear  fluid  in  which  urea, 
albumen,  and  chlorides  can  be  detected,  and  which  is  there- 
fore a  true  renal  secretion.  Sebaceous  glands  appear  in  the 
skin  at  the  fiith  month,  the  sweat-glands  somewhat  later. 
The  structm^e  of  the  foetal  epidermis  is  very  simple,  the 
horny  layer  being  practically  absent,  and  transudation  from 
the  foetal  capillaries  into  the  Hquor  amnii  probably  takes 
place  T^dth  ease.  The  traces  of  urea  found  in  the  amniotic 
fluid  may  therefore  reach  it  directly  from  the  blood  by 
passing  through  the  skin.  The  vernix  caseosa  is  the  abun- 
dant product  of  the  active  sebaceous  glands.  The  meco- 
nium found  distributed  in  the  gut  of  the  mature  foetus,  from 
the  duodenum  to  the  rectum,  is  chiefly  composed  of  the  waste 
products  of  the  hepatic  secretion.  It  also  often  contains 
numbers  of  lanugo  hairs  and  squamous  epithehal  cells,  which 
can  be  recognised  under  tha  microscope  ;  the  only  possible 
way  in  which  they  can  reach  the  intestine  is  by  the  foetus 
swallowing  quantities  of  its  hquor  amnii,  in  which  these 
elements  are  always  to  be  found  in  suspension.  The  uniform 
distribution  of  this  substance  throughout  the  gut  indicates 
that  peristalsis  is  present  in  the  foetal  intestines,  otherwise 
accumulation  in  the  upper  part  would  necessarily  take  place. 

The  Gravid  Uterus 

The  uterus  undergoes  a  remarkable  series  of  changes 
during  pregnancy,  which  are  without  parallel  in  any  other 
organ.  They  result  in  an  increase  of  weight  from  1|  to 
2  ounces  before  impregnation,  to  2  to  2|  lbs.  at  term. 

Changes  in  Shape  and  Size. — During  the  first  month  of 
gestation  the  uterus  undergoes  no  chnically  appreciable 
alteration  in  shape  or  size,  but  towards  the  end  of  the  second 


GRAVID   UTERUS 


63 


month  well-marked  alterations  are  apparent.  The  body  of 
the  normal  non-gravid  uterus  has  the  shape  of  a  pear  flat- 
tened in  an  antero-posterior  plane  ;  during  the  second 
month  it  expands  in  the  antero-posterior  plane,  but  is  still 
wider  at  the  fundus  than  below.  At  the  eighth  week  the 
uterine  body  measures  about  2  inches  in  vertical  by  1^  inches 
(5  cm.  by  4  cm.)  in  transverse  diameter  (Fig.   43).     The 


D.S, 


Fig.  43. — Gravid  Uterus  at  End  of  Second  Month  (Eighth  Week), 
From  a  Frozen  Section.     (Braune.) 

The  uterus  is  retro  verted,  but  shows  the  expansion  of  the  body-cavity.     B.C.  Decidna 
capsularis.     D.S.  Deeidua  basalis  (serotina).     D.V.  Decidua  vera. 


normal  anterior  inclination  of  the  uterus  is  now  somewhat 
exaggerated,  and  the  angle  between  body  and  cervix  may 
be  slightly  diminished  (anteflexion).  At  the  end  of  the  third 
month  (twelve  to  thirteen  weeks)  it  is  nearly  globular  in 
shape,  and  has  greatly  increased  in  size,  measuring  about 
3^  to  4  inches  (9  cm.  to  10  cm.)  in  diameter  (Fig.  44).  It 
has  now  become  large  enough  to  fill  the  pelvic  cavity,  and 
in  a  primigravida  (a  woman  pregnant  for  the  first  time)  may 
be  felt  just  above  the  level  of  the  pubes  on  abdominal 


64 


NORMAL  PREGNANCY 


palpation.     In  a  multipara  it  is  often  higher  than  this.     At 
the  end  of  the  fourth  month  it  has  again  become  distinctly 


Fig.  44. — Gravid  Uterus  at  the  Thirteenth  Week.     (Galabiii  and 
Blacker.) 

pyriform  in  shape  (Fig.  45)  ;  the  vertical  diameter  is  about 
6  inches  (15  cm.),  and  the  fundus  may  be  felt  somewhat 
nearer  the  umbihcus  than  the  pubes.     The  pyriform  shape 


GRAVID   UTERUS 


65 


is  henceforth  preserved  until  term.  Measurements  of  the 
height  of  the  fundus  above  the  pubes  are  somewhat  falla- 
cious, but  at  the  end  of  the  fifth  month  (twenty- two  weeks) 
the  uterus  usually  extends  to  the  level  of  the  umbilicus  ; 
at  the  end  of  the  seventh  month  (thirty-one  weeks)  it  is 


Os 
//  Internum 


Utero  vesical 
pouch 


Fig.  45. — Gravid  Uterus  at  Beginning  of  Fifth  Month  (Eighteenth  Week). 
From  a  Frozen  Section.     (Clarence  Webster.) 

midway  between  the  umbilicus  and  the  tip  of  the  xiphoid 
cartilage  ;  the  highest  point  is  reached  about  two  weeks 
before  term,  when  the  fundus  extends  to  the  tip  of  the  xiphoid 
cartilage,  and  often  passes  upwards  beneath  the  costal 
margin  slightly  everting  the  lower  ribs.  It  then  sinks  a 
little  lower  in  the  abdomen  ;  this  descent  is,  however,  not 
observed  in  every  case,  and  may  be  delayed  until  labour 

E.M.  5 


66  NORMAL   PREGNANCY 

has  actually  commenced.  The  average  height  of  the  fundus 
above  the  pubes  at  term  is  about  10  to  12  inches  (25  cm.  to 
30  cm.),  being  a  Httle  greater  in  a  multipara  than  in  a  primi- 
gravida  :  the  widest  transverse  diameter  of  the  uterus  is 
8|  to  9  inches  (21  cm.  to  22  cm.).  As  seen  in  frozen  sections, 
the  uterus  from  the  fifth  month  onwards  is  markedly 
moulded  posteriorly  upon  the  vertebral  column  (Figs.  45 
and  46). 

The  ovum  does  not  completely  fill  the  uterine  cavity  until 
the  end  of  the  third  month  (Figs.  15  and  44)  ;  until  then  a 
space  persists,  known  as  the  decidual  space,  lying  below, 
or  below  and  to  one  side  of  the  ovum.  During  the  fourth 
month  the  decidua  vera  and  capsularis  become  closely 
apposed,  obhterating  this  space,  and  bringing  the  ovum 
directly  over  the  os  internum  (Fig.  45)  ;  the  same  relation 
is  thence  maintained  to  term. 

Changes  in  Relations. — The  position  of  the  gravid  uterus 
after  it  has  risen  out  of  the  pelvis  is  rarely  precisely  mesial ; 
it  is  usually  deflected  to  one  or  other  side,  more  often  to  the 
right  than  the  left.  This  is  called  the  lateral  obliquity  of  the 
uterus.  It  is  also  believed  that  rotation  on  a  vertical  axis 
occurs,  bringing  one  or  other — usually  the  left — cornu 
forwards  towards  the  abdominal  wall.  This  rotation  can 
sometimes  be  observed  when  the  uterus  is  exposed  in  the 
operation  of  Csesarean  Section.  The  normal  position  of  ante- 
version  (tilting  forwards)  of  the  body  of  the  uterus  is  often 
exaggerated  during  the  first  two  months  ;  afterwards  the 
uterine  axis  becomes  almost  erect ;  later  still  the  organ 
becomes  moulded  upon  the  vertebral  column,  and  towards 
the  end  of  pregnancy  the  tendency  to  anteversion  again 
appears,  especially  in  multiparse  with  lax  abdominal  walls 
(Fig.  50)  ;  these  changes  in  the  degree  of  anteversion  produce 
corresponding  variations  in  the  position  of  the  cervix  which 
are  appreciable  to  clinical  examination.  Thus  during  the 
first  two  months  the  cervix  is  carried  backwards  by 
exaggerated  anteversion  of  the  fundus,  until  the  external  os 
is  difficult  to  reach  with  the  finger.  Later  on  it  becomes 
more  central,  and  the  os  is  easily  reached.  As  term 
approaches  the  cervix  again  becomes  displaced  backwards  by 
descent  of  the  head,  and  it  may  be  quite  difficult  to  reach  it 
when  labour  sets  in. 


GRAVID   UTERUS 


67 


The  relations  of  the  uterus  to  its  peritoneal  investment 
undergo  considerable  changes.  The  uterine  peritoneum 
develops  pari  passu  with  the  growth  of  the  uterus,  and  the 
anterior  and  posterior  peritoneal  pouches  are  preserved 
(Figs.  45  and  46).  The  utero-sacral  folds  rise  up  to  the  level 
of  the  pelvic  brim,  and  since  the  level  of  its  floor  remains 
unaltered,  the  pouch  of  Douglas  at  term  is  very  deep  indeed. 


Utero 

pouch 


Bladder 

Fig.  46. — Frozen  Section  of  Griavid  Uterus  at  Term.     (Leopold  ) 

The  lateral  reflections  also  rise  considerably,  so  that  at  term 
the  bases  of  the  broad  ligaments  may  be  described  as  being 
at  the  level  of  the  pelvic  brim  (Barbour)  ;  this  leaves  a  large 
area  of  the  lowest  part  of  the  uterine  wall  on  each  side 
uncovered  by  peritoneum.  Considerable  increase  of  con- 
nective tissue  between  the  folds  of  the  broad  ligament,  in 
relation  to  each  lateral  uterine  wall,  occurs  during  pregnancy. 
The  round  ligaments  undergo  considerable  hypertrophy,  so 
that  they  may  in  some  circumstances  be  palpated  through 

5—2 


68  NORMAL   PREGNANCY 

the  abdominal  walls.  The  bladder  remams  a  pelvic  organ 
up  to  term,  and  the  level  of  the  utero-vesical  pouch  is 
unaltered  throughout  pregnancy  (Fig.  46). 

Changes  in  the  Uterine  Muscle. — The  presence  of  a 
developmg  ovum  in  the  uterus  sets  up  a  progressive  series  of 
changes  in  that  organ  of  a  hj^Dertrophic  character,  the 
immediate  effect  of  which  is  to  enable  the  uterus  to  contain 
the  foetus  during  the  whole  period  of  its  growth.  These 
changes  in  the  uterus  may  be  suitably  designated  as  "  active 
dilatation.'"'  They  must  be  regarded  as  a  part  of  the 
general  physiological  reaction  of  the  maternal  organism  in 
pregnane}^;  to  which  further  reference  will  shortly  be  made. 

The  average  thickness  of  the  uterine  wall  at  term  is  about 
half  that  of  the  non-pregnant  organ,  which  is  from  f  to  1  inch 
(2  cm.  to  2-5  cm.),  but  there  are  variations  ui  different  parts. 
The  posterior  wall  is  fairly  equal  throughout  ;  the  anterior 
becomes  thinner  in  its  lower  part  before  it  joins  the  cer\ax. 
Both  hj^ertrophy  of  existing  muscle  fibres,  and  new  forma- 
tion of  muscle,  occur  in  the  gravid  uterus.  Increase  of  the 
elastic  tissue  is  also  said  to  occur,  but  the  connective-tissue 
elements  of  the  uterus  are,  generally  speaking,  much  less 
affected  than  the  muscular  elements.  According  to  KoUiker, 
the  muscle  fibres  in  the  second  half  of  pregnancy  are  ten  times 
as  long  and  twice  as  broad  as  in  the  non-gravid  state.  New 
formation  of  muscle  fibres  only  occurs  durmg  the  first  six 
months,  and  affects  chiefly  the  deeper  layers  of  the  muscula- 
ture. The  fibres  are  said  to  become  striated  to  some  extent 
towards  the  close  of  pregnancy.  During  the  course  of  preg- 
nancy a  more  or  less  definite  arrangement  of  the  musculature 
of  the  body  of  the  uterus  into  three  layers  occurs,  but  this 
change  does  not  affect  the  cer^dx.  The  outer  layer  consists 
partly  of  longitudinal,  partly  of  transverse  fibres  ;  the  former 
are  found  in  the  form  of  a  broad  mesial  band,  running  from 
the  level  of  the  internal  os  in  front  over  the  fundus  to  the 
same  level  behind  ;  the  latter  cross  the  uterus  ui  front  and 
behind  and  pass  out  into  the  broad  hgaments.  The  middle 
layer  greatly  exceeds  either  of  the  other  two  in  thickness  and 
is  closely  united  vdth.  them  ;  it  forms  a  close  reticulum  of 
interlacing  fibres,  through  which  run  the  large  arterial  and 
venous  channels  ;  around  the  vessels  it  forms  powerful  rmgs 
of  arcuate  fibres  arranged  somewhat  in  the  form  of  figures  of 


LOWER   UTERINE   SEGMENT  60 

8.  The  internal  layer  is  very  thin,  and  is  composed  mostly 
of  annular  fibres,  which  encircle  the  whole  uterus,  and  are 
specially  developed  at  the  cornua  around  the  openings  of  the 
Fallopian  tubes. 

The  Lower  Uterine  Segment. — It  has  been  mentioned  that 
the  lower  part  of  the  anterior  uterine  wall  becomes  thinned 
for  a  short  distance  above  the  level  of  the  internal  os.  Over 
this  part  the  peritoneal  coat  is  loosely  attached,  and  can  be 
readily  stripped  off.  It  will  be  remembered  that  in  the  non- 
gravid  uterus  the  peritoneum  is  loosely  attached  in  the  same 
position.  Upon  the  posterior  wall  there  is  neither  thinning 
of  wall  nor  loose  attachment  of  peritoneum.  The  part  of  the 
uterine  body  roughly  corresponding  to  the  area  of  loose 
peritoneal  attachment  is  called  the  lower  uterine  segment. 
It  was  until  recently  believed  that  the  lower  segment  could 
be  precisely  defined  in  this  manner,  but  it  now  appears  that 
the  area  of  loose  peritoneal  attachment  is  subject  to  much 
greater  variation  than  was  formerly  supposed  (Barbour). 
Although  defined  in  this  way  only  upon  the  anterior  wall,  the 
lower  uterine  segment  forms  a  complete  zone.  It  is  said  that 
microscopically  the  arrangement  of  the  bundles  of  muscle 
fibres  is  somewhat  different  in  the  lower  segment  from  the 
remainder  of  the  uterus  (Barbour).  Its  special  functions  are 
connected  with  the  process  of  labour,  and  the  subject  will  be 
again  referred  to  in  that  connection  (see  p.  274).  The  normal 
situation  of  the  placenta  is  any  part  of  the  uterine  wall  above 
the  lower  segment  ;  when  the  placental  site  encroaches  upon 
this  part  of  the  uterus  the  condition  of  placenta  prcevia  is  pro- 
duced. The  development  of  the  lower  segment  in  pregnancy 
can  be  traced  roughly  by  measuring  the  distance  between  the 
internal  os  and  the  level  of  firm  peritoneal  attachment  ;  in 
this  way  it  has  been  shown  to  increase  from  2-3  cm.  at  the 
fourth  month  to  6  cm.  at  term.  From  what  has  been  said  of 
the  relations  of  the  peritoneum  it  will  be  perceived  that  at 
term  the  lateral  aspects  of  the  lower  segment  have  no 
peritoneal  investment,  for  they  lie  between  the  layers  of  the 
broad  ligaments,  the  bases  of  which  are  greatly  elevated. 

The  Cervix  undergoes  few  alterations  of  importance 
during  pregnancy.  It  preserves  the  naked  eye  characters  of 
its  mucous  membrane,  which  does  not  become  transformed 
into  a  decidua  (Fig.  44) .    It  has  recently  been  shown,  however, 


70  NOEMAL  PREGNANCY 

that  decidual  cells  may  be  found  in  the  upper  part  of  the 
cervical  mucous  membrane,  and  it  is  therefore  probable  that 
the  changes  characteristic  of  pregnancy  do  not  end  abruptly 
at  the  internal  os,  but  may  be  traced  in  diminishing  degree 
into  the  cervix  (Aschoff).  Its  muscular  coat  does  not  hyper- 
trophy, and  it  preserves  the  usual  arrangement  of  its  fibres  in 
a  dense  network.  Its  relations  to  vaginal  vault,  cellular 
tissue,  and  peritoneum  remain  unaltered.  It  was  formerly 
believed,  from  clinical  observations,  that  the  cervix  became 
shortened  diu'uig  pregnancy  ;  the  study  of  frozen  sections  of 
the  gravid  uterus  i7i  situ  has  shown  that  the  length  of  the 
canal  is  fairly  constant  and  does  not  differ  from  that  of  the 
non-gravid  organ  (Fig.  97).  CHnically,  however,  a  marked 
change  occurs  which  is  known  as  '  softening  of  the  cervix.' 
It  is  found  fii'st  at  the  lips  of  the  os  externum  and  gradually 
advances  from  below  upwards  mitil  at  term  the  whole  of  the 
portio  vaginalis  is  softened.  The  histology  of  this  change  is 
obscure,  and  up  to  the  present  time  no  satisfactory  study  of 
it  has  been  made  ;  increased  vascularity  probably  explains 
it  in  part.  The  surface  of  the  portio  vaginalis  undergoes  a 
variable  degree  of  blue  discoloration  early  in  pregnancy.  As 
term  approaches  the  internal  os  often  becomes  a  little  dilated 
in  a  multipara,  and  the  same  change  is  occasionally  found  in  a 
primigravida. 

Uterine  Contractions. — Throughout  pregnancy  the  uterine 
muscle  manifests  a  certain  amount  of  activity.  Inter- 
mittent contractions  take  place,  feeble  in  the  early  months, 
but  becoming  more  pronounced  as  the  uterus  develops,  which 
bear  a  general  resemblance  to  the  uterine  contractions,  or 
'  pains,'  of  labour.  They  are  intermittent  and  involuntary, 
but  they  differ  from  the  contractions  of  labour  in  being  pain- 
less— the  patient  is  quite  unconscious  of  them.  Being 
palpable  b}-  abdominal  examination,  they  form  a  clinical  sign 
of  great  diagnostic  importance  in  the  later  months  of  preg- 
nancy. They  are  probably  excited  by  some  reflex 
mechanism,  in  which  the  ovum  provides  the  peripheral 
stimulus  ;  while  the  active  hypertrophy  of  the  uterine  muscle 
makes  the  response  to  this  stimulus  very  pronounced.  Even 
when  spontaneous  contractions  are  imperceptible,  hardening 
and  contraction  of  the  uterus  can  usually  be  induced  hy  a 
gentle  stimulus,  such  as  rubbing  with  the  hand. 


MAMMARY   GLANDS  71 

The  General  Physiology  of  Pregnancy 

The  presence  of  a  developing  ovum  in  the  uterus  occasions 
a  progressive  series  of  changes  not  only  in  the  containing 
organ  but  in  the  whole  of  the  maternal  organism.  In 
addition  to  the  uterine  changes,  widespread  alterations  occur 
involving  both  the  structure  and  the  function  of  many  of  the 
most  important  organs  in  the  body.  There  can  be  no  doubt 
that  a  potent  physiological  force  resides  in  the  developing 
ovum  and  scarcely  a  single  function  of  the  maternal  orga- 
nism but  feels  its  influence.  The  recognition  of  the  exis- 
tence of  this  force  is  the  chief  contribution  which  has  been 
made  in  recent  years  to  the  science  of  obstetrics.  The  study 
of  the  question  naturally  presents  great  technical  difficulties, 
and  demands  expert  biological  and  biochemical  knowledge. 
The  practical  obstetrician  can  do  no  more  than  carefully 
examine  the  work  of  scientific  observers,  and  endeavour  to 
gather  from  their  results  a  general  view  of  the  problem  which 
may  be  useful  in  understanding  clinical  phenomena,  and  in 
dealing  with  abnormal  developments. 

The  General  Physiological  Changes  in  Pregnancy. — Under 
this  heading  must  be  grouped  not  only  the  well-known  and 
obvious  changes  such  as  those  which  occur  in  the  breasts,  but 
also  the  recently  discovered  and  more  obscure  alteration 
which  occurs  for  instance  in  the  endocrinous  glands  and  in  the 
blood  serum.  Physiological  forces  must  be  studied  mainly 
through  the  effects  they  produce  ;  at  this  early  stage  of  our 
knowledge,  therefore,  it  will  be  necessary  to  speak  chiefly  of 
structural  and  chemical  changes,  and  little  of  the  manner  in 
which  they  are  brought  about. 

Mammary  Glands. — These  organs  cannot  be  said  to  be 
fully  developed  until  pregnancy  has  occurred,  and  has  been 
followed  by  a  period  of  lactation.  In  a  primigravida  (a 
woman  in  her  first  pregnancy)  they  undergo  a  series  of 
changes,  many  of  which  persist  after  the  glands  have  returned 
to  their  resting  phase ;  the  breasts  of  a  parous  woman  who  has 
suckled  her  children  therefore  differ  greatly  from  those  of  a 
nullipara.  The  size  of  the  mamma  is  very  variable  in  tiealthy 
women,  as  are  also  the  size  and  appearance  of  the  nipple  and 
areola.  In  a  first  pregnancy  the  whole  gland  increases  in 
size,  and  undergoes  a  true  hypertrophy,  which  affects  not 


72 


NORMAL  PREGNANCY 


only  the  glandular  acini,  but  also  the  connective-tissue 
stroma  (Fig.  47).  This  hj^Dcrtrophy  is  first  recognisable 
clinically  in  the  peripheral  lobules  of  the  gland,  which 
become  tense,  nodular,  and  slightly  tender  to  the  touch. 
It  usually  appears  at  about  the  end  of  the  second  month, 
although  it  may  be  delayed  until  the  fourth  month.  When 
the  hypertrophy  of  the  lobules  is  well  marked,  a  little  clear 
pale-yellow  secretion  can  usually  be  expressed  by  gently 
compressing  the  base  of  the  gland  and  squeezing  it  towards 

the  nipple.  The  nipple 
and  areola  become  more 
deeply  pigmented,  but 
this  change  varies  much 
in  intensity  in  women 
of  different  complexion, 
being  more  marked  in 
brunettes  than  in 
blondes.  Upon  the 
areola  a  series  of  ten  to 
twenty  small  non-pig- 
mented  nodules  appear, 
consisting  of  enlarged 
sebaceous  glands,  and 
known  as  '  Montgomery's 
tubercles '  (Fig.  48) ;  they 
are  not,  however,  inva- 
riably present.  Usually 
the  areola  becomes  more 
prominent  than  normal, 
and  around  it  is  formed  an  outer  zone  of  irregular  and 
less  marked  pigmentation,  known  as  the  secondary  areola. 
As  shown  in  Fig.  48,  the  secondary  areola  usually  consists 
of  a  well-defined  reticulum,  forming  a  tesselated  arrangement 
of  pale  quadrilateral  areas  enclosed  in  the  meshes  of  a  pig- 
mented web.  An  increased  vascular  supply,  indicated  by 
dilated  veins  under  the  skin,  accompanies  the  hypertrophy. 
Often  towards  the  close  of  a  first  pregnancy  the  skin  itself 
becomes  stretched,  and  small  patches  of  the  cutis  vera 
becoming  thinned,  give  rise  to  the  appearances  known  as 
strice  (see  p.  75).  The  secretion  varies  in  character  during 
pregnancy  ;  when  first  seen  it  is  usually  a  thin  straw-coloured 


Fig.  47. — The  Mamma  in  a  late 

of  Pregnane}",  showing  the  Secon- 
dary Areola.  (Galabin  and  Blacker.) 


Mammary  glands 


73 


fluid  resembling   serum  ;     later  it   becomes   thicker,   more 
opaque,  and  more  distinctly  yellow  in  colour. 

In  the  breasts  of  a  multipara  the  changes  characteristic 
of  early  pregnancy  can  seldom  be  detected,  for  the  reasons 
stated  above.  After  a  period  of  full  functional  activity 
(suckling)  a  little  Tnilk  may  be  present  in  the  breasts  for 
several  years  and  may  be  found  on  squeezing  them.  But  if 
the  breasts  of  a  multipara  contain  thin  serous  fluid  instead 


Fig.  48. — -The  Nipple  and  Areola  of  aPrimigravida,  showing  tlie  Tubercles 
of  Montgomery,  the  Secondary  Areola,  and  several  dilated  veins. 


of  milk,  a  fresh  phase  of  activity,  i.e.,  an  early  pregnancy 
is  indicated. 

These  changes  indicate  an  '  activation  '  of  the  mammary 
glands  during  pregnancy,  which  is  recognisable  from  the 
second  month  onwards.  In  degree  and  in  the  rate  of  advance 
considerable  variation  may  be  noted,  but  the  glands  never 
remain  absolutely  quiescent  during  pregnancy.  The  acme 
of  the  process  of  activation  does  not  occur  however,  until 
three  or  four  days  after  the  birth  of  the  child  (see  p.  559). 
The  breasts  then  become  engorged  with  secretion  to  an 
extent  which  makes  them  swollen  and  painful,  but  which  is 


74  XORIMAL   PREGXAXCY 

fully  relieved  by  the  natural  process  of  suckling.  Once  fully 
established,,  mammary  activity  will  be  maiatairied  for  several 
months,  under  the  stimulus  of  suckling,  without  the  renewal 
of  the  original  physiological  stimulus.  Occasionally  puer- 
peral activation  is  deficient,  and  the  mother  has  not  enough 
milk  to  feed  her  child. 

The  means  by  which  pregnancy  induces  mammary 
activity  are  not  known,  but  there  can  be  no  doubt  that  there 
is  a  dii^ect  relation  of  cause  and  effect  between  them.  No 
other  condition  than  pregnancy  can  excite  the  mammary 
function  to  i^r\-yihmg  like  the  same  extent  ;  the  stimulus 
is  continuous  and  progressive  in  intensitj^  throughout 
pregnancy  ;  untimely  interruption  of  ]Dregnancy  leads 
to  immediate  mammary  retrogression.  The  physiological 
mechanism  at  work  is  probably  complex.  Biochemical 
changes  are  no  doubt  the  main  factor,  and  in  accordance  with 
the  physiological  nomenclature  of  to-day  it  may  be  said  that 
a  '  hormone  "  is  probably  produced  in  the  gravid  uterus,  which 
directly  or  indirectly  acts  upon  the  mammary  gland. 
AATaether  the  hormone  is  of  maternal  or  foetal  origin  is  not 
determined,  and  the  point  is  not  of  great  importance.  Star- 
ling and  Lane-Claypon  experimentally  produced  mammary 
hypertrophy  in  virgin  rabbits  hj  injection  of  extracts  made 
from  the  foetus  of  the  rabbit,  and  from  this  result  they 
conclude  that  the  mammary  stimulus  is  of  foetal  origin. 
These  conclusions,  however,  must  await  confirmation.  The 
fact  that  mammary  activity  persists  for  so  long  after  the 
production  of  the  pregnancy '  hormone '  has  ceased,  indicates 
that  the  action  is  indirect.  It  has  been  suggested  by  Schafer 
that  this  iadirect  action  may  be  exerted  through  the  pitui- 
tary gland.  It  is  known  that  in  animals  this  gland  under- 
goes weh  marked  hypertrophy  in  pregnancy ;  if  it  may 
be  assumed  that  the  same  change  occurs  in  women,  then 
the  persistence  of  this  hypertrophy  may  explain  the  hyper- 
secretion of  the  early  puerperium  and  the  continuance  of 
activity,  aided  only  by  the  mechanical  stimulus  of  suckling, 
during  the  period  of  lactation. 

Cutaneous  System. — The  changes  occurring  in  the  cuta- 
neous system  may  be  arranged  iii  two  groups  ;  some  are 
mechanical  and  are  due  to  stretching  of  the  skin,  such  as  the 
strise  ;    -others    are    truly   biological,   such   as    pigmentary 


CUTANEOUS   SYSTEM  75 

changes,  malnutrition  of  the  cutaneous  appendages,  and  the 
appearance  of  eruptions. 

Strice  gravicla7'U7n  appear  on  the  abdominal  wall  similar 
to  those  found  on  the  breasts.  When  recently  formed  they 
are  pearly  or  pinkish  in  colour,  and  linear  in  outline  ;  they 
vary  in  length  and  breadth,  and  are  most  marked  below 
the  umbilicus  ;  sometimes  they  are  also  seen  on  the  adjacent 
parts  of  the  buttocks  and  thighs.  After  labour  is  over  they 
become  pale  and  silvery,  i.e.  cicatricial,  and  are  known  as 
strice  albicantes.  In  a  multipara  some  may  be  found  in 
the  recent  state,  others  are  old,  and  represent  the  changes 
which  have  occurred  in  a  previous  pregnancy.  The  capacity 
of  the  skin  to  resist  the  effects  of  stretching  varies  in  indivi- 
duals, for  sometimes  these  marks  are  not  produced  at  all  in 
pregnancy.  On  the  other  hand,  similar  striae  may  be  pro- 
duced by  abdominal  distension  due  to  causes  other  than 
pregnancy. 

Pigmentary  changes. — The  changes  in  the  breasts  have 
been  already  referred  to.  On  the  abdomen  a  mesial  line 
of  pigmentation,  running  from  above  the  umbihcus  to  the 
pubes,  appears  during  the  second  half  of  pregnancy  ;  it  is 
called  the  linea  nigra.  In  a  dark  complexioned  woman  it 
may  be  broad  and  dark  and  in  a  fair  woman  it  may  be  barely 
visible.  In  dark  complexioned,  non-pregnant  women  a 
similar  line  may  sometimes  be  seen,  so  that  its  presence  is 
not  a  sure  indication  of  pregnancy.  On  the  face  irregular 
patches  of  dark  brown  pigmentation  sometimes  occur,  being 
most  marked  on  the  forehead,  the  sides  of  the  nose,  and  the 
upper  lip,  but  the  whole  face  may  be  affected.  It  is  called 
the  pregnancy  mark  or  chloasma.  Sometimes  extensive 
pigmentation  occurs  on  the  trunk  in  irregular  patches, 
alternating  with  patches  from  which  the  natural  pigment 
has  largely  disappeared.  In  some  cases  the  distribution 
is  not  unlike  that  seen  in  Addison's  disease.  As  a  rule  the 
pigmentary  changes  disappear  after  labour,  but  sometimes, 
on  the  trunk,  they  remain  permanent. 

Signs  of  malnutrition  may  be  found,  such  as  an  increased 
tendency  to  falling  of  the  hair  ;  in  the  same  category,  as 
teeth  are  of  epidermal  origin,  may  be  placed  the  rapid  advance 
of  dental  caries. 

Eruptions   of  erythematous,  papular,  or  pustular  type 


76  NORMAL   PREGNANCY 

are  frequent  accompaniments  of  morbid  complications  of 
pregnancy. 

Circulatory  System. — The  blood  undergoes  modifications 
which  are  fairly  constant,  and  upon  which  observers  are 
agreed.  In  animals  the  total  volume  of  the  blood  is  increased 
during  pregnancy,  and  the  same  change  can  fairly  be 
assumed  to  occur  in  women.  The  quality  of  the  blood, 
however,  deteriorates,  for  the  proportion  of  water  increases, 
while  the  proportions  of  red  cells  and  hsemoglobin  diminish  ; 
these  evidences  of  anaemia  are  most  marked  about  the  middle 
of  pregnancy,  but  even  at  term  the  average  number  of  red 
cells  is  under  4,000,000  per  cmm.  A  definite  excess  of  white 
corpuscles  is  found  in  the  blood  during  pregnancy,  the  excess 
being  much  higher  in  a  primigravida  than  a  multipara.  It 
is  most  marked  towards  the  close  of  pregnancy,  when  the 
numbers  vary  from  8,000  to  15,000  (Carton).  During  labour 
a  fiu-ther  increase  up  to  20,000  occurs,  and  after  labour  the 
number  may  reach  25,000  (Pankow),  but  thereafter  rapidly 
falls.  The  specific  gravity  is  progressively  diminished  up  to 
the  middle  of  pregnancy,  and  rises  again  to  normal  at  term. 
The  amount  of  calcium  salts  present  is  shghtly  increased, 
while  that  of  fibrin  diminishes  up  to  the  sixth  month, 
when  it  begins  to  rise  again  to  normal  at  term.  It  t\t.11  thus 
be  seen  that  a  certain  deterioration  in  the  quality  of  the 
blood  is  evident  during  the  first  half  of  pregnane}^ 

The  heart  was  for  a  long  time  believed  to  undergo  hyper- 
trophy during  pregnancy.  There  has  been  much  conflict  of 
observation  upon  the  point,  but  Lohlein  asserts  that  the 
weight  of  the  organ  is  not  appreciably  increased,  and  there- 
fore there  can  be  no  hypertrophy.  A  certain  amount  of 
dilatation  probably  occurs,  affecting  chiefly  the  right  side 
of  the  organ.  Arterial  tension  is  believed  to  be  increased 
slightly  during  pregnancy,  but  it  is  very  variable,  and  clmical 
observations  have  failed  to  settle  the  question  definitely.  In 
the  venous  system  evidences  of  increased  back-pressure  are 
frequently  found  in  the  form  of  haemorrhoids,  slight  anasarca 
of  the  feet,  and  varices  of  the  lower  extremities  and  vulva. 

Blood  pressure  is  believed  to  be  slightly  raised  during  the 
later  months  of  pregnancy,  but  great  differences  of  opinion 
exist  as  to  what  is  the  normal  for  young  adult  non-pregnant 
women.     From  recent  clinical  observations  Bailey  estimates 


DUCTLESS   GLANDS  77 

that  a  pressure  of  1 18  mm.  of  Hg  is  normal  for  the  last  month, 
and  this  is  hardly  above  the  average.  In  certain  morbid 
conditions,  notably  eclampsia,  a  high  blood  pressure,  which 
may  reach  150  mm.  to  200  mm.,  is  commonly  found,  but  the 
point  is  not  one  of  practical  importance  when  conditions  are 
normal. 

The  Endocrinous  (Ductless)  Glands. — Recent  investiga- 
tions have  shown  that  these  organs  undergo  remarkable 
changes  in  the  direction  of  '  activation  '  in  animals,  and  it 
may  be  assumed  with  confidence  that  they  occur  in  women- 
also.  It  has  been  known  to  clinical  observers  for  generations 
that  goitre  underwent  rapid  enlargement  during  pregnancy, 
and  careful  observation  has  shown  that  the  normal  gland 
often  undergoes  enlargement  also.  The  other  endocrinous 
glands  are  inaccessible  to  clinical  examination,  and  con- 
firmation of  their  participation  in  pregnancy- enlargement 
can  only  be  gathered  as  opportunity  offers.  It  may  be  said, 
however,  that  in  animals  the  pituitary,  the  pineal,  the 
adrenals,  the  thymus,  and  the  parathyroid  bodies  all  show 
enlargement  accompanied  by  minute  changes  in  their  cells 
indicative  of  hyperactivity.  The  conclusion  is  that  the 
amount  of  their  internal  secretion  is  raised  above  the  normal, 
and  the  physiological  effects  they  produce  are  exaggerated. 
The  functions  of  these  glands  are  by  no  means  fully  known, 
but  certain  of  the  general  effects  of  pregnancy  already 
described  may  very  well  be  due  to  them.  Thus  the  activa- 
tion of  the  mammary  glands  and  the  rise  in  blood  pressure 
may  be  brought  about  indirectly  through  the  pituitary,  the 
pigmentation  of  the  skin  through  the  adrenals,  the  leucocy- 
tosis  through  the  spleen,  and  the  increased  output  of  calcium 
through  the  ovaries. 

Other  Organs. — The  nervous  system  becomes  functionally 
disturbed  in  women  of  neurotic  tendencies,  and  such  con- 
ditions are  manifested  as  irritability,  sleeplessness  or  constant 
drowsiness,  neuralgia,  perversion  of  appetite  by  the  so-called 
'  longings,'  &c.  But  in  women  whose  nervous  system  is  in  a 
state  of  stable  equilibrium  these  disturbances  of  function  do 
not  occur.  Towards  the  end  of  pregnancy  the  size  of  the 
uterus  causes  some  embarrassment  of  respiration,  which 
becomes  almost  entirely  costal  in  type  ;  and  cramps  in  the 
muscles  of  the  legs  are  frequent  from  pressure  upon  the  lumbar 


78  N0R:^L4L   PREGNANCY 

and  sacral  plexuses.  The  bladder  usually  shows  some  irrita- 
biUty  about  the  second  month,  but  this  passes  off  and  does 
not  recur  until  the  close  of  pregnancj%  when  not  uncommonly 
micturition  again  becomes  frequent  and  painful.  Nausea 
and  vomiting  are  usually  present  in  the  early  months  (see 
Morning  Sickness,  p.  85),  and  there  is  a  common  tendency  to 
constipation  and  the  formation  or  aggravation  of  haemorr- 
hoids. A  slight  decrease  in  the  total  acidity  of  the  gastric 
secretion  and  in  the  amomit  of  free  hydrochloric  acid 
accompanies  pregnancy.  The  pelvic  articulations  undergo 
slight  softening  of  hgaments  and  general  loss  of  firmness  and 
strength. 

The  liver  also  enlarges  and  becomes  congested,  and  cer- 
tain recent  observers  have  maintained  that  a  zone  of  slight 
fatt}^  degeneration  may  be  fomid  in  the  centre  of  the  hepatic 
lobule  around  the  portal  vein,  w^hich  is  dilated.  It  has  been 
shoT^Ti  that  the  glycolytic  fmiction  of  the  hver  is  diminished, 
and  fm-ther  evidences  of  disordered  fmiction  are  to  be  found 
in  the  diminished  excretion  of  extractives  by  the  kidneys. 

There  is  also  evidence  that  many  other  organs,  not 
directly  coimected  with  the  generative  system,  show  definite 
changes  in  pregnancy.  Thus,  patches  of  congestion  and 
swelling  of  the  mucous  membrane  of  the  larynx  commonly 
occur,  resulting  in  alteration  of  the  tone  and  quahty  of  the 
voice  in  singers.  Similar  patches  of  congestion  and  swelling 
occur  in  the  mucous  membranes  of  the  bladder  and  ureter. 

Excretory  Functions. — It  has  been  known  for  a  long  time 
that  the  amount  of  carbonic  acid  thrown  off  by  the  lungs 
is  distinctly  increased  during  pregnancy.  Observations  upon 
the  functions  of  the  skhi  have  not  been  made,  but  great 
attention  has  of  late  years  been  paid  to  the  condition  of  the 
urine,  and  the  following  facts  have  been  estabhshed.  The 
daily  quantity  of  urine  is  frequently  below  the  average  in 
primiparse.  The  proportion  of  total  solids  diminishes 
steadily  up  to  term,  the  fall  being  due  to  diminution  in  the 
amounts  of  uric  acid,  urea,  phosphates,  sulphates,  creatin, 
and  creatinin.  A  fan  average  excretion  of  urea  for  a  preg- 
nant woman  on  an.ordhiary  mixed  diet  is  estimated  at  r25 
per  cent.  Of  the  total  nitrogen  excretion  the  proportion 
excreted  as  vu'ea  is  normal,  but  the  proportion  excreted  as 
ammonia  is  slightlj^  increased.     A  study  of  the  nitrogen 


EXCRETIONS  79 

intake  and  output  has  shown  that  towards  the  end  of  preg- 
nancy the  mother  is  storing  nitrogen  at  a  rate  considerably 
in  excess  of  the  nitrogenous  requirements  of  the  foetus, 
which  are  estimated  at  1  grain  a  day.  Sometimes 
sugar  is  found  in  the  urine  of  healthy  pregnant  women 
towards  term,  and  this  has  been  shown  to  be  due,  in  most 
cases,  to  lactose  derived  from  the  mammary  secretion, 
although  alimentary  glycosuria  may  also  occur.  Lactose 
is  also  very  frequently  found  in  the  urine  of  nursing  women. 
It  will  be  observed  that  the  solid  constituents  of  the  urine 
which  are  diminished  are  chiefly  '  purin  bodies  ' — urea, 
uric  acid,  creatin,  creatinin — and  disturbance  of  the  func- 
tions of  the  liver  is  probably  the  cause  of  this  alteration. 

Recent  observations  have  shown  that  during  normal 
pregnancy  the  excretion  of  Hme  salts  is  greatly  increased, 
and  an  excess  is  usually  to  be  found  in  the  blood.  This 
appears  to  result  from  a  certain  decalcification  of  bone,  as 
the  amount  excreted  exceeds  that  ingested  in  the  later  months 
of  pregnancy.  The  excess  in  the  blood  may  in  part  be  used 
for  the  processes  of  foetal  ossification. 

The  glycolytic  function  of  the  liver  is  also  impaired 
during  pregnancy,  and  according  to  Bar  it  is  reduced  to 
one  half  of  the  normal.  This  is  evidenced  by  the  rapid 
appearance  of  sugar  in  the  urine  after  ingestion. 

Elaborate  chemical  investigations  of  the  excretory  func- 
tions in  pregnancy  have  been  carried  out  by  Bar,  who  has 
estimated  the  relation  between  the  ingestion  in  foodstuffs, 
and  the  excretion  through  the  urine  and  fseces,  of  nitrogen, 
lime  salts,  phosphorus,  &c.  The  details  of  such  an  investi- 
gation are  unsuitable  for  consideration  in  a  text-book  ;  the 
general  conclusion  at  which  Bar  arrived  may,  however,  be 
stated.  He  considered  that  his  observations  showed  that 
definite  alterations  in  the  maternal  metabolism  are  recognis- 
able in  pregnancy,  the  assimilation  and  output  of  the  chief 
tissue  constituents  being  regulated  so  as  to  provide  what  is 
required  for  the  formation  and  growth  of  the  foetus.  So 
accurately  is  metabolism  adjusted  that  the  maternal 
organism  suffers  no  loss  during  pregnancy,  but  can  be  shown 
actually  to  lay  up  larger  stores  of  certain  elements.  He  was 
thus  led  to  regard  the  state  of  pregnancy  as  a  '  harmonious 
symbiosis,' 


80  NORMAL   PREGNANCY 

Other  observers  have  been  led  in  the  opposite  direction, 
viz..  to  the  conclusion  that  a  condition  of  toxoemia  is  developed 
during  pregnancy.  The  earhest  observations  of  this  character 
were  those  of  Bouchard  upon  the  toxicity  of  the  urine. 
The  methods  employed  are  necessarily  somewhat  complex, 
and  they  cannot  be  described  here  in  detail  ;  but  it  may  be 
said  briefl}^  that  they  consist  in  determining  the  amount  of 
urine  which  ^vill  produce  death  when  injected  directly  into 
the  vein  of  an  animal,  usually  a  rabbit  or  guinea-pig.  This  is 
called  the  urotoxic  dose,  and  it  can  be  compared  with,  the 
urotoxic  dose  of  the  urine  of  a  healthy  non-pregnant  woman, 
which  is  taken  as  the  standard.  If  the  urotoxic  dose  is  larger 
in  the  pregnant  than  in  the  non-pregnant,  then  the  toxicity 
of  the  urine  is  less,  and  vice  versa.  Contradictory  results 
have  been  obtained  by  this  method,  and  extreme  care  is 
required  in  conducting  the  observations  ;  a  majority  of 
observers,  however,  assert  that  a  slight  diminution  in  the 
toxicitj^  of  the  urine  can  be  detected  from  the  end  of  the 
second  month  up  to  term,  but  it  rapidly  disappears  after 
labour.  From  this  basis  a  theory  has  been  built  up  that  a 
toxic  condition  of  the  blood  exists  in  normal  pregnane}^,  for 
if  less  toxic  matter  is  excreted  it  must  be  assumed  to  accumu- 
late in  the  blood  ;  and  this  is  called  the  toxcemia  of  pregnancy . 
Confirmation  of  the  theory  has  been  sought  by  making 
observations  in  a  similar  manner  upon  the  toxicity  of  the 
blood-serum  of  pregnant  women  ;  but  the  results  of  these 
observations  are  of  very  little  value,  omng  to  difficulties  of 
experimental  technique.  It  is,  however,  obvious  that  if  an 
increase  in  the  toxicity  of  the  blood  could  be  experimentally 
proved  to  occur  during  pregnancy,  the  existence  of  a  con- 
dition of  '  toxaemia  '  could  not  be  denied.  For  the  present 
it  must  be  said  that  these  observations  have  not  succeeded  in 
demonstrating  the  existence  of  a  toxic  condition  of  the  blood 
in  normal  pregnancy  ;  but,  as  we  shall  see  later,  they  have 
been  of  great  service  in  throwing  light  upon  the  causation  of 
some  of  the  disorders  of  pregnancy. 

In  the  last  few  j^ears  the  matter  has  been  carried  further 
by  numerous  observations  upon  the  serum  reaction  in  preg- 
nancy, which  will  now  be  referred  to. 

Serum  Reactions  in  Pregnancy. — The  greatest  advance 
which  has  been  made  in  recent  vears  in  the  studv  of  the 


ABDERHALDEN'S   TEST  81 

biology  of  pregnancy  is  the  discovery  by  Abderhalden  of  a 
specific  serum  reaction,  which  is  now  known  as  Abder- 
halden's  test. 

This  test  is  based  upon  the  principle,  now  well  estabh'shed 
by  numerous  instances,  that  the  introduction  into  the 
blood  of  an  organic  foreign  substance  leads  to  the  formation 
of  a  special  ferment  which  will  destroy  it.  Thus  cane  sugar 
injected  into  the  blood  leads  to  the  formation  of  a  ferment 
— invertin,  which  reduces  it  ;  injection  of  foreign  proteids 
leads  to  the  formation  of  proteolytic  ferments  which  break 
them  up.  Each  ferment  thus  produced  is  specific,  i.e.,  it  is 
able  to  break  up  only  a  particular  proteid.  Abderhalden's 
plan  was  to  try  to  discover  whether  the  blood  of  a  pregnant 
woman  contained  a  ferment  capable  of  destroying  placental 
proteid. 

The  fact  that  fragments  of  chorionic  epithehum  enter 
the  maternal  blood  vessels,  and  are  carried  to  distant  parts, 
has  been  already  referred  to.  One  of  the  first  observers  of 
the  migration  of  fragments  of  syncytium  into  the  blood- 
stream was  Veit.  His  observations  led  him  to  conceive  the 
idea  that  the  presence  of  this  substance  in  the  blood  might 
be  deleterious,  and  might  become  the  means  of  exciting  the 
production  of  a  protective  body  or  antigen,  the  function  of 
which  would  be  to  destroy  the  syncytium.  To  this  hypo- 
thetical protective  body  he  gave  the  name  of  syncytiolysin. 
It  will  be  obvious  that  Abderhalden's  test  takes  up  the 
idea  enunciated  by  Veit,  and  seeks  to  put  it  to  a  biological 
proof.  Abderhalden  desired  to  find  out  whether  these 
fragments  of  foetal  epithelium  are  disposed  of  in  the  blood 
by  a  ferment. 

The  details  of  Abderhalden's  test  are  very  comphcated, 
and  only  an  outhne  can  here  be  given.  The  isolation  of 
the  ferment  itself  being  impracticable,  his  test  aims  at  the 
detection  of  substances  known  to  be  end-products  of  the 
process  of  proteolytic  digestion  of  all  kinds  of  proteids. 

The  first  step  is  to  prepare  from  fresh  normal  placental 
tissue,  carefully  freed  from  blood  and  handled  with  infinite 
precaution,  a  solution  of  placental  peptones,  by  partial 
digestion  with  an  acid.  Blood  serum  from  a  pregnant 
woman,  and  serum  from  a  non-pregnant  woman  for  use  as 
a  control,  are  then  brought  into  contact  with  the  placental 

B.M.  6 


82  NORMAL   PREGNANCY 

peptone  solution.  The  former  freely  breaks  up  the  peptones  ; 
the  latter  does  not,  or  does  so  only  to  a  shght  extent.  The 
destruction  of  the  peptones  is  demonstrated  by  recognising 
in  the  solution  amino-acids,  knoT^n  to  be  the  end-products 
of  proteolytic  digestion.  Two  methods  of  demonstrating 
amino-acids  may  be  employed,  viz.,  by  the  polarimeter,  or 
by  dialysation  and  a  colour  reaction  ;  the  latter,  although 
miuch  more  complex,  is  also  more  dehcate,  and  by  it  a  chlution 
of  1 — 25,000  may  be  detected. 

By  this  test  Abderhalden  claims  to  have  proved  that  the 
blood  serum  of  a  pregnant  woman  contains  a  specific  sub- 
stance, of  the  nature  of  an  enzyme,  which  possesses  the  power 
of  breaking  up  placental  proteids  ;  that  the  blood  of  non- 
pregnant women  does  not  contain  this  body  ;  and  that,  in 
consequence,  the  biological  reaction  which  he  has  discovered 
may  be  used  as  a  means  of  diagnosing  pregnancy.  He 
further  claims  to  have  shown  that  foetal  blood  does  not 
contain  the  ferment.  It  must,  however,  be  stated  that 
some  observers,  working  with  the  test,  have  failed  to  cor- 
roborate Abderhalden's  results,  while  other  workers,  in  con- 
firmation of  Abderhalden,  have  sho^Ti  that  positive  reactions 
may  be  obtained  in  pregnancy  from  the  eighth  week  onwards, 
and  also  up  to  the  tenth  day  of  the  puerperium. 

Evidence  is  accumulating  that  there  are  many  sources 
of  error  to  be  guarded  against  in  the  appHcation  of  the  test, 
which  can  only  be  carried  out  by  an  expert  pathological 
chemist.  Unless  due  precautions  are  observed,  positive 
reactions  in  the  non-pregnant  may  be  obtained.  At  the 
same  time  the  main  features  of  Abderhalden's  test  have  now 
been  confirmed  by  numerous  workers,  and  according  to 
Wilhamson,  it  holds  good  for  extra-uterine  as  well  as  for 
normal  pregnancy,  and  perhaps  even  for  chorion-epithe- 
lioma. 

The  significance  of  these  observations,  if  they  can  be 
rehed  upon,  is  undoubtedly  very  great.  They  indicate  that 
there  is  present  in  the  blood  of  a  pregnant  woman  a  sub- 
stance against  which  the  organism  must  be  protected,  i.e., 
a  toxic  substance,  and  that  a  specific  means  is  organised  for 
.  its  destruction.  And  fmlher,  they  show  that  it  is  derived 
from  fcetal  elements  of  the  placenta,  and  that  the  blood  of 
the  foetus  itself  does  not  contain  the  toxic  substance.     In 


ABDERHALDEN'S   TEST  83 

other  words,  the  mother  is  constantly  absorbing  products 
derived  from  the  placenta,  which  to  her  are  noxious,  and 
must  therefore  be  disposed  of.  So  long  as  the  defensive 
mechanism  is  acting  adequately,  she  may  suffer  no  ill  effects  ; 
should  the  defensive  mechanism  break  down,  such  ill  effects 
may  reasonably  be  anticipated,  although  we  cannot  foretell 
what  form  they  may  assume. 

This  biological  reaction  suggests  an  easy  explanation 
of  the  profound  and  widespread  changes  in  the  maternal 
organism  in  pregnancy  which  have  been  already  described. 
Some  of  them,  such  as  the  activation  of  the  endocrinous 
glands,  may  be  a  part  of  the  defensive  mechanism  ;  others 
may  be  the  unfavourable  result  of  toxic  influences.  And 
further,  it  suggests  that  certain  of  the  grave  disorders  of 
pregnancy,  which  will  be  described  in  a  later  section,  may 
be  due  to  accumulation  of  the  placental  toxins  in  the 
blood,  either  from  failure  of  the  defensive  mechanism,  or 
from  excessive  production  of  toxins.  Pregnancy  would 
appear  to  be  a  condition  in  which  health  and  disease  are  very 
delicately  balanced,  and  morbid  influences  are  particularly 
liable  to  become  preponderant. 

Many  trained  workers  are  now  engaged  in  the  attempt 
to  apply  Abderhalden's  work  to  the  elucidation  of  the 
diseases  of  pregnancy,  but  the  problems  to  be  solved  are 
very  complex,  and  much  remains  to  be  done.  Certain 
observers  have  endeavoured  to  show  that,  in  addition  to 
Abderhalden's  reaction,  other  reactions  can  be  obtained 
from  blood  serum  which  are  characteristic  of  a  condition  of 
immunity,  comparable  to  that  which  is  developed  in  recovery 
from  bacterial  infection.  This  view  would  necessitate 
pregnancy  being  regarded  as  a  disease  of  parasitic  origin, 
comparable  to  a  specific  fever,  and  in  the  meantime  it  has 
not  passed  further  than  the  stage  of  suggestion. 

The  Diagnosis  of  Pregnancy 

The  Hmits  of  age  within  which  pregnancy  may  occur  are 
very  wide.  It  is  rare  before  puberty,  and  even  more  rare 
after  the  menopause.  Yet  authentic  instances  of  pregnancy 
have  been  observed  at  the  age  of  eight  or  nine  years  in  girls 
in  whom  menstruation  had  appeared  abnormally  early.     And 

6—2 


84  NORMAL  PREGNANCY 

several  authentic  cases  have  also  been  recorded  after  the 
menopause,  one  of  these  being  a  woman  of  fifty-nine  who 
had  ceased  to  menstruate  for  nine  years  (Depasse).  It  may, 
however,  be  said  that  pregnancy  is  extremely  uncommon 
before  thirteen  and  after  fifty. 

The  nomenclature  of  the  duration  of  pregnancy  is  some- 
what confusing.  In  this  country  it  is  usual  to  speak  of  nine 
calendar  months  as  the  period  of  gestation,  but  this  is 
inexact.  It  is  agreed  that  the  average  duration  of  pregnancy 
is  from  274  to  280  days  ;  neither  of  these  periods  represents 
precisely  nine  months,  for  the  number  of  days  in  nine  months 
is  variable  ;  but  the  latter  does  represent  exactly  ten  times 
four  weeks.  It  would  avoid  confusion  to  estimate  the 
duration  of  pregnancy  in  weeks  instead  of  months. 

During  the  second  half  of  pregnancy  the  presence  of  a 
foetus  in  the  uterus  can  be  directly  recognised  by  palpation 
and  auscultation.  During  the  first  haK  this  is  impossible, 
and  diagnosis  then  depends  upon  the  careful  observation  of 
a  certain  series  of  symptoms  (facts  elicited  from  the  patient), 
and  physical  signs  (facts  observed  by  the  physician).  The 
practical  value  of  being  able  to  recognise  pregnancy  at  aU 
periods  is  very  great,  and  the  subject  therefore  demands  the 
most  careful  attention. 

I.  Diagnosis  of  Pregnancy  during  the  First  Half. — 
Symptoms. — Those  met  with  during  this  period  are  amenor- 
rhcea,  morning  sickness,  irritabihty  of  the  bladder,  discom- 
fort and  swelling  of  the  breasts,  enlargement  of  the  abdomen, 
and  '  quickening.'  It  must  be  understood  that  not  one  of 
these  symptoms  occurring  alone,  nor  even  all  of  them 
occurring  together,  can  be  regarded  as  conclusive  evidence 
of  pregnancy.  They  allow  of  the  '  presumptive  diagnosis  ' 
of  pregnancy,  but  a  definite  opinion  should  never  be 
expressed  in  any  case  until  a  physical  examination  has  been 
made.  And  further,  until  the  tenth  week  has  been  reached, 
the  changes  in  the  uterus  itseK  are  not  sufficiently  definite 
to  allow  of  a  physical  diagnosis  being  made  unless  the  con- 
ditions are  specially  favourable. 

Amenorrhoea. — Cessation  of  the  menses  is  practically 
invariable  in  pregnancy  ;  cases  are  said  to  occur  in  which 
regular  menstruation  continues  for  the  first  two  or  three 
months,  but  they  are  extremely  rare,  when  pathological 


DIAGNOSIS  85 

bleeding  can  be  excluded.  Even  in  double  uteri,  men- 
struation ceases  as  a  rule,  although  only  one  half  of  the 
organ  is  gravid.  Irregular  haemorrhage  from  pathological 
causes  is  not  uncommon  in  pregnant  women,  but  this 
should  not  be  confounded  with  menstruation.  Sudden 
cessation  of  the  menses  in  a  healthy  woman  habitually 
regular,  and  not  near  the  age  of  the  menopause,  affords  a 
strong  presumption  of  pregnancy.  Amenorrhoea  usually, 
though  by  no  means  invariably,  continues  during  suckling, 
and  it  is  also  common  in  chlorosis,  in  hysteria,  and  in  some 
forms  of  insanity.  In  addition  to  its  value  as  a  presumptive 
symptom  of  the  existence  of  pregnancy,  amenorrhoea  affords 
the  best  means  of  estimating  its  duration.  It  is  usual  to 
reckon  the  commencement  of  pregnancy  from  the  last 
regular  menstrual  period.  This  method  is  certainly  falla- 
cious, for  pregnancy  may  occur  during  a  period  of  amenor- 
rhoea due  to  some  other  cause,  such  as  suckling ;  and  it  takes 
no  account  of  the  fact  that  the  date  of  fruitful  sexual  inter- 
course does  not  necessarily  correspond  with  the  cessation  of 
menstruation,  but  it  is  the  best  method  which  is  available 
for  the  purpose.  Sometimes,  however,  the  duration  of 
pregnancy  must  be  estimated  from  other  data,  such  as  the 
size  of  the  uterus. 

It  is  not  known  why  the  presence  of  a  developing  ovum 
in  the  uterus  causes  the  immediate  arrest  of  menstruation. 
There  is  a  certain  amount  of  evidence  that  ovulation  con- 
tinues, or  may  continue,  during  pregnancy  (see  Super- 
foe  tation,  p.  100),  which  makes  the  cessation  of  menstruation 
the  more  remarkable.  It  has  been  suggested  that  a  body 
is  produced  during  pregnancy  which  antagonises  the  internal 
ovarian  secretion,  and  thus  arrests  the  menstrual  process. 
It  is  possible  that  such  a  body  may  be  present  also  in  the 
mammary  secretion,  which  would  account  for  the  amenor- 
rhoea of  lactation.  After  the  fourth  month,  when  the 
decidual  space  has  been  obliterated,  of  course  menstruation 
cannot  occur,  for  the  uterine  mucous  membrane  has 
practically  ceased  to  exist,  except  as  a  part  of  the  placenta. 

Morning  Sickness. — This  symptom  is  by  no  means 
invariable  in  pregnancy.  The  great  majority  of  primi- 
gravidse  suffer  from  it,  but  in  subsequent  pregnancies  it  is 
frequently  absent.     It  usually  appears  at  the  beginning  of 


86  NORMAL   PREGNANCY 

the  second  month — i.e.,  soon  after  the  first  suppressed  period 
— and  it  varies  greatly  in  severity.  Some  pregnant  women 
are  seized  with  nausea,  ending  in  vomiting,  immediately  on 
rising  or  after  their  first  meal  ;  the  vomiting  once  over,  there 
is  no  further  discomfort  nor  any  loss  of  appetite  during  the 
rest  of  the  day.  Others  are  subject  to  nausea,  without 
vomiting,  which  may  last  for  several  hours  and  is  more 
troublesome  than  the  first-named  variety.  But  m  neither 
case  is  the  general  health  affected,  and  the  tongue  remains 
clean.  All  gradations  may  be  observed  between  this 
sym23tom  and  the  serious  disorder  of  pregnancy  known  as 
hyperemesis  (see  p.  126).  Morning  sickness  in  either  of 
these  common  forms  usually  lasts  for  only  a  few  weeks, 
rarely  for  more  than  three  months.  The  modern  tendency 
is  to  regard  it  as  a  toxic  symptom.  It  must  be  remembered 
that  in  chronic  alcoholism  morning  sickness,  sometimes 
associated  with  amenorrhcea  and  abdominal  enlargement, 
may  be  met  with  apart  from  pregnancy  ;  but  the  tongue  i^ 
furred,  and  the  careful  observer  will  detect  other  changes 
characteristic  of  this  condition. 

Irritability  of  the  bladder,  shown  by  frequency  of  mic- 
turition with  some  pain  or  discomfort,  is  usual  during  the 
second  and  third  months,  and  is  caused  in  part  by  the 
pressure  of  the  heavy  anteverted  uterus,  in  part  by  the 
congestion  of  the  mucosa  of  the  bladder  previously 
referred  to  (p.  78).  After  the  third  month,  when  the  uterus 
rises  above  the  pelvic  brim  and  becomes  more  erect,  the 
pressure  is  removed,  and  this  symptom  disappears  or 
becomes  alleviated. 

Enlargement  of  the  breasts  is  often  noticed  early  by  a 
primigravida,  but  enlargetnent  of  the  abdomen  usually  .does 
not  become  manifest  to  the  patient  until  the  uterus  rises  well 
above  the  pubes,  and  therefore  seldom  attracts  attention 
until  the  close  of  the  first  half  of  pregnancy.  A  multipara, 
owing  to  the  laxity  of  the  abdominal  wall,  usually  notices 
abdominal  enlargement  earlier  than  a  primigravida. 

Quickening. — This  term  in  its  ancient  significance  means 
'  coming  to  life,'  and  indicates  that  the  mother  has  become 
aware  of  the  existence  of  something  which  is  ahve  and 
moving  within  her.  The  first  movements  of  the  foetus 
which  are  felt  by  the  mother  sometimes  produce  a  sensation 


DIAGNOSIS  87 

of  more  or  less  severe  nausea  or  faintness,  and  to  this  symp- 
tom the  term  '  quickening  '  is  applied.  Many  women  do  not" 
experience  it,  and  find  it  impossible  to  tell  when  the  move- 
ments of  the  foetus  first  became  obvious  to  them,  so  gradual 
has  been  their  development.  When  a  definite  history  can 
be  obtained,  quickening  is  usually  found  to  occur  between 
the  sixteenth  and  eighteenth  weeks.  Foetal  movements 
continue  until  the  end  of  pregnancy  and  are  chiefly  important 
in  the  later  months  as  an  indication  that  the  child  is  alive. 
The  mother  continues  to  be  conscious  of  these  movements, 
as  a  rule,  unless  the  child  dies. 

Physical  Signs. — During  the  first  few  weeks  no  changes 
occur  which  can  be  detected  by  clinical  investigation,  and 
unless  the  conditions  are  specially  favourable  the  earliest 
period  at  which  pregnancy  can  be  diagnosed  is  the  eighth 
week.  We  therefore  take  up  the  physical  signs  at  the  latter 
period. 

Eighth  Week. — At  this  period  the  breasts  of  a  primi- 
gravida  may  present  recognisable  indications  of  activity, 
but  frequently  they  show  no  change  until  the  following 
month.  Some  hypertrophy  of  the  peripheral  lobules  of  the 
glands,  indicated  by  a  nodular  feel  and  slight  tenderness, 
may  be  apparent,  while  the  areolar  changes  described  on 
p.  72  may  also  be  detected.  Occasionally  a  little  clear 
serum  may  be  expressed  by  gently  squeezing  the  base  of  the 
gland  towards  the  nipple.  In  the  case  of  a  multipara  no 
importance  can  be  attached  to  the  existence  of  these  signs, 
as  they  frequently  persist  in  a  gland  which  has  previously 
passed  through  the  period  of  functional  activity  associated 
with  suckling,  or  even  with  pregnancy  alone.  Secretion  is 
also  sometimes  found  in  the  breasts  of  non-pregnant  nuUi- 
parous  women  suffering  from  uterine  disease,  such  as  a 
fibroid  tumour. 

Examination  of  the  abdomen  at  this  period  is  of  no  value, 
but  changes  in  the  uterus  may  be  detected  by  a  careful 
bi-manual  examination.  Softening  of  the  lips  of  the  os 
externum  may  be  made  out,  but  is  not  very  marked,  and 
may  be  mistaken  by  the  student  for  the  condition  clinically 
known  as  '  erosion  '  ;  examination  with  a  speculum  will  clear 
up  this  difficulty,  unless  erosion  of  the  cervix  and  pregnancy 
co-exist.     If  the  abdominal  wall  is  thin  and  lax,  the  body  of 


88 


NORMAL   PREGNANCY 


the  uterus  can  be  taken  between  the  fingers  of  the  two  hands, 
and  its  increased  size,  almost  globular  shape,  and  soft  con- 
sistence detected.  Another  important  change  known  as 
Hegar's  sign  must  also  be  looked  for. 

Hegar's  sign  is  the  result  of  certain  anatomical  conditions 
which. are  characteristic  of  the  second  and  third  months  of 
pregnancy.  It  will  be  recollected  that  at  this  period  the 
ovum  does  not  completely  occupy  the  uterine  cavity,  an 
empty  space  being  left  in  the  lower  part,  called  the  decidual 
space.  At  this  period  also  the  walls  of  the  uterus  have 
become  distinctly  softened,  and  perhaps  somewhat  thinned. 


Abdominal    wall 


Body  of  uterus 


Compressible 

lower  uterine 

segment 


Fig.  49. — Schematic  Eepresentation  of  Hegar's  Sign.     (After  Hegar.) 

The  body  of  the  uterus  is  therefore  in  its  upper  part  soft  and 
distended  by  the  ovum,  in  its  lower  part  soft  and  empty. 
The  lower  part  is  consequently  unusually  compressible  by  the 
fingers  in  bi-manual  examination,  and  Hegar's  sign  consists 
in  the  recognition  of  this  unusual  degree  of  compressibility. 
To  obtain  it,  the  uterus  should  be  anteverted,  although  even 
in  the  retroverted  position  it  can  be  elicited  in  a  modified 
manner.  Bi-manual  examination  is  made  with  the  patient 
lying  on  her  back,  the  shoulders  shghtly  raised,  and  the 
knees  well  flexed.  Two  fingers  of  the  right  hand  are  mtro- 
duced  into  the  vagina  and  placed  immediately  in  front  of  the 
cervix  ;   the  left  hand  is  placed  over  the  suprapubic  region. 


DIAGNOSIS  89 

The  uterus  is  then  pushed  upwards  from  the  vagina  towards 
the  abdominal  wall  until  it  can  be  distinctly  felt  by  the  left 
hand.  The  fingers  of  the  left  hand  are  now  passed  over  the 
posterior  surface  of  the  uterus,  and  when  the  two  hands  work 
together  the  lower  part  of  the  uterine  body  can  be  com- 
pressed between  them  (Fig.  49).  Two  points  wiU  then  be 
noticed  :  first,  the  ease  with  which  the  fingers  can  be  approxi- 
mated and  the  walls  of  the  uterus  compressed  ;  and  secondly, 
the  tense  elastic  consistence  of  the  upper  part  of  the  uterus, 
which  forms  a  marked  contrast  to  the  lower  part.  When 
the  uterus  is  retroverted,  the  compressibility  of  the  lower 
part  can  be  made  out  with  a  finger  in  the  rectum  and  the 
other  hand  on  the  abdominal  wall  ;  but  the  upper  part  of  the 
body  is  not  so  easily  accessible  as  in  the  position  of  ante- 
version,  consequently  the  contrast  between  the  upper  and 
lower  parts  cannot  well  be  made  out.  A  certain  amount  of 
skill  and  experience  in  gynaecological  examination  is  neces- 
sary for  the  recognition  of  this  sign,  but  its  value  is  very 
great  when  clearly  perceived. 

To  sum  up,  it  may  be  said  that  pregnancy  at  the  eighth 
week  can  be  diagnosed  from  the  conjunction  of  the  following 
series  of  symptoms  and  physical  signs  : 


Symptoms. 

1.  Amenorrhoea. 

2.  Morning  sickness. 

3.  Irritability  of  bladder. 


Signs. 

1 .  Slight  breast  changes  (in  a  primi- 

gravida). 

2.  Lips  of  OS  externum  softened. 

3.  Uterine  body  enlarged,  softened, 

nearly  globular  in  shape. 

4.  Hegar's  sign. 


Sixteenth  Week. — Amenorrhoea  continues,  but  morning 
sickness  and  urinary  symptoms  have  usually  disappeared  by 
this  time.  It  is  ^-bout  this  period  that  quickening  is  to  be 
expected.  The  enlargement  of  the  breasts  has  become  quite 
obvious  to  the  patient  if  she  is  a  primigrav^da,  but  abdominal 
enlargement  may  not  yet  have  attracted  her  attention. 

Hypertrophy,  increased  pigmentation,  and  presence  of 
secretion  in  the  breasts  can  now,  as  a  general  rule,  be  made 
out.  The  linea  nigra  will  be  quite  obvious  in  dark-com- 
plexioned women.  The  uterus  is  large  enough  to  be  felt 
rising  to  a  height  of  about  3  inches  above  the  level  of  the 
symphysis  pubis.     It  forms  an  elastic,  somewhat  ill-defined, 


90  NORIVIAL   PREGNANCY 

mesial  abdominal  swelling,  with  a  convex  upper  border.  The 
characteristic  duU  violet  coloration  of  the  vulval  mucous 
mem.brane  is  now  recognisable,  but  its  extent  and  intensity 
are  variable.  The  cervix  shows  more  extensive  softening, 
and  at  this  period  forms  one  of  the  most  characteristic  and 
easily  recognisable  features  of  pregnancy.  If  exposed  with 
a  speculum  the  same  violet  coloration  will  be  noticed  as  at 
the  vulva.  Pulsating  vessels  can  often  be  felt  at  the  sides  of 
and  behind  the  cervix — the  enlarged  vaginal  arteries.  The 
abdominal  swelling  can  be  recognised  as  the  uterus  by  bi- 
manual examination  ;  its  shape  is  now  passing  from  globular 
to  pyriform  ;  its  consistence  is  intermediate  between  the 
hardness  of  a  sohd  mass  and  the  lax  softness  of  a  cyst,  and 
is  usually  described  as  '  elastic  '  ;  but  some  experience  is 
required  to  detect  with  confidence  these  varieties  of  consis- 
tence. Hegar's  sign  can  no  longer  be  made  out.  Two  other 
signs  of  great  importance  can  often  be  recognised  at  this 
period  in  the  uterus — viz.,  uterine  contractions  and  internal 
ballottement. 

The  fact  that  the  gravid  uterus  undergoes  contractions 
has  been  already  referred  to  ;  they  are  not  recognisable 
chnically  much  earlier  than  the  period  under  consideration, 
but  it  is  possible  that  they  exist  in  some  form  from  the 
begimiing  of  pregnancy.  They  are  feeble  contractions,  and 
as  detected  at  the  end  of  the  fourth  month  they  merely 
render  the  uterus  a  little  firmer  and  better  defined  in  outhne. 
Care  and  a  prolonged  hi-manual  examination  are  required  for 
their  detection,  for  the  intervals  between  them  may  be  con- 
siderable ;  they  sometimes  appear  to  be  increased  by 
manipulating  the  uterus.  If  the  abdominal  wall  is  thick  or 
rigid,  or  the  patient  intolerant  of  the  examination,  this  sign 
cannot  be  made  out,  and  no  importance  must  be  attached  to 
a  failure  to  elicit  it  ;  but  its  positive  value  is  considerable. 
It  sometimes  occurs,  however,  apart  from  pregnancy,  in  soft 
fibroid  tumours,  and  has  been  recognised  in  the  enlarged 
uterus  in  cases  of  extra-uterine  gestation.  Sometimes  partial 
or  unequal  contractions  occur  affecting  portions  only  of  the 
uterus  ;  as  a  result  the  shape  of  the  uterus  may  be  distorted 
and  its  consistence  may  appear  to  be  different  in  different 
parts.  After  an  interval  it  resumes  its  normal  shape  and 
uniform  consistence. 


DIAGNOSIS 


91 


Internal  ballottement  consists  in  the  detection  in  the  uterus 
of  a  movable  sohd  body  surrounded  by  fluid.  If  during  a 
bi-manual  examination  the  foetus  should  chance  to  lie  upon 
the  lower  part  of  the  anterior  uterine  wall,  the  fingers,  sharply 
pressed  into  the  anterior  fornix,  will  displace  it  upwards 
through  the  amniotic  fluid,  and  the  sensation  of  its  disappear- 
ance will  be  felt  ;  if  the  fingers  are  kept  in  position  a  slight 
impact  may  be  felt  a  moment  later,  indicating  its  return  to 
its  original  position.  The  return  is  often  missed,  but  the 
displacement  of  the  foetus  can  frequently  be  detected.  The 
foetus,  however,  often  occupies  a  position  where  it  is  out  of 
reach  of  the  fingers  on  vaginal  examination,  and  this  sign 
cannot  then  be  elicited.  It  is  more  easily  obtained 'in  the 
erect  than  in  the  supine  position.  It  will  be  remembered 
that  at  this  period  the  size  of  the  foetus  is  small  in  comparison 
with  that  of  the  uterus. 

Pregnancy  at  the  sixteenth  week  can  therefore  be  diag- 
nosed from  the  following  : 


Symptoms. 

Signs. 

1. 

AmenorrhcBa. 

1. 

Active  breast  changes. 

2. 

Quickening. 

2. 

Linea  nigra ;  elastic  hypogastric 
swelling  (uterus). 

3. 

History  of  recent  morning  sick- 

3. 

Cervix  softened. 

ness. 

4. 

Uterine  contractions,  internal 
ballottement. 

II.  Diagnosis  of  Pregnancy  during  the  Second  Half. — 
Symptoms. — The  symptoms  during  the  second  half  of  preg- 
nancy are  of  little  diagnostic  importance,  since  unmistakable 
evidence  is  furnished  by  the  physical  signs.  Amenorrhoea 
continues  ;  a  good  deal  of  mammary  discomfort  is  often 
experienced  by  a  primigravida,  owing  chiefly  to  the  increased 
weight  of  the  enlarged  glands.  Towards  the  end  of  this 
period  symptoms  of  increased  intra-abdominal  pressure 
appear,  such  as  oedema  of  the  feet  and  cramps  in  the  lower 
extremities,  varicose  veins  in  the  legs  and  vulva,  and  some- 
times, from  upward  pressure  on  the  diaphragm,  palpitations 
and  dyspnoea.  About  two  to  three  weeks  before  the  onset 
of  labour  these  symptoms  all  undergo  a  somewhat  abrupt 
amelioration,  popularly  known  as  the  '  lightening  '  ;  this  is 
due  to  descent  of  the  presenting  part  of  the  foetus  into  the 


92 


NOR^IAL  PREGNANCY 


pelvic    brim,    and    consec|iient    relief    of    intra-abdominal 
pressure. 

Physical  Signs. — Twenty -sixth  WeeJ:  [end  of  Sixth  Calen- 
dar Month). — Hypertrophy  of  the  mammae  is  now  mimis- 
takable  :  secretion  can  be  freely  expressed  ;  pigmentary 
areolar  changes  have  become  intensified. 

Abdomen. — Protuberance  of  the  lower  half  of  the  abdo- 
men is  now  clearly 
.  visible,  and  a  few  re- 
cent striae  may  be  ob- 
served below  the  level 
of  the  umbilicus  ;  the 
hnea  nigra  in  dark 
women  is  pronounced. 
On  palpation  the  fun- 
dus of  the  uterus  will 
be  found  at  the  level 
of  the  upper  border  of 
the  umbihcus  (Fig.  50). 
The  uterus  is  distinctly 
pyriform  in  shape,  and 
usualh^  extends  further 
to  the  right  than  to  the 
left  of  the  mesial  plane 
— 7'ight  lateral  obliquity. 
Occasionally  the  obli- 
quity is  to  the  left, 
but  the  uterus  is  seldom 
exactly  mesial.  Its 
general  consistence  is 
elastic,  but  it  does  not 
yield  a  fluid  thrill. 
Contractions  can  usu- 
ally be  felt  when  it  is  gently  palpated  with  the  hands  for 
two  or  three  minutes.  From  the  period  when  the  fmidus 
becomes  palpable  above  the  pubes,  it  rises,  when  developing 
normally,  a  little  less  than  |  inch  a  week. 

In  addition  certain  other  signs  may  be  detected  on 
abdominal  examination  which  are  not  found  at  earlier 
periods  ;  these  are,  on  palpation,  external  ballottement  and 
spontaneous  fcEtal    movements ;     and    on    auscultation    the 


Fig.  50. — Schematic  Eepresentation  of 
the  Height  of  the  Fundus  and  the 
Shape  of  the  Abdomen  in  Pregnancy. 
(Roberts.) 

The  fisrures  indicate  weeks. 


DIAGNOSIS  93 

uterine  souffle  and  the  foetal  heart-sounds.  Palpation  of  foetal 
movements  and  auscultation  of  the  foetal  heart  are  positive 
or  absolute  signs  of  the  presence  of  a  living  foetus,  and  their 
detection  renders  the  diagnosis  of  pregnancy  not  presump- 
tive, but  certain. 

At  the  twenty-sixth  week,  the  foetus,  though  large  enough 
to  be  readily  felt  on  abdominal  palpation,  moves  freely,  for  it 
is  still  small  in  comparison  with  the  size  of  the  uterine  cavity. 
The  palms  of  both  hands  should  be  gently  laid  over  the  uterus, 
and  while  one  hand  is  used  to  steady  it,  the  fingers  of  the 
other  hand  make  a  series  of  quick  but  gentle  impacts  upon 
it  ;  the  whole  anterior  surface  and  sides  of  the  uterus  are 
gone  over  in  this  way.  At  some  part  or  other  the  fingers  will 
come  down  upon  the  body  or  a  limb  of  the  foetus  ;  the  latter 
immediately  recedes  before  the  impact,  but  gives  a  distinct 
momentary  sense  of  contact  with  a  freely  movable  body. 
This  is  called  external  hallottement.  Sometimes  the  foetus  can 
be  displaced  in  this  way  across  the  uterus,  and  thus,  as  it 
were,  tossed  from  one  hand  to  the  other.  While  using  the 
hands  in  this  manner,  spontaneous  movement  of  some  part  of 
the  foetus,  probably  a  limb,  will  often  be  detected,  proving 
not  only  that  there  is  a  foetus  present,  but  that  it  is  ahve. 
Care  is  required  in  eliciting  these  signs,  but  they  are  of  great 
diagnostic  value.  As  pregnancy  advances  the  spontaneous 
movements  made  by  the  foetus  become  much  more  manifest, 
and  during  the  last  six  or  eight  weeks  they  are  felt  by  the 
mother  as  energetic  and  even  violent  movements  from  which 
she  is  not  free  for  more  than  a  few  hours  at  a  time,  and  which 
often  disturb  sleep.  Moving  freely  in  its  bag  of  liquor  amnii 
the  foetus  thus  takes  exercise,  which  is  no  doubt  of  import- 
ance in  the  development  of  the  muscular  system.  The 
principal  movements  are  made  by  the  limbs,  but  movements 
of  the  trunk  also  occur  resulting  in  changes  of  '  position  '  and 
'  presentation  '  (see  p.  262). 

Uterine  Souffle. — From  the  middle  of  pregnancy  onwards, 
a  soft,  blowing,  systolic  murmur,  sjmchronous  with  the 
mother's  pulse,  can  usually  be  heard  on  auscultation  of  the 
gravid  uterus.  It  is  best  heard  at  the  lowest  part  of  the 
lateral  borders,  but  may  sometimes  be  loud  enough  to  be 
audible  over  a  large  part  of  the  anterior  surface  of  the  uterus. 
In  seeking  this  sign  the  uterus  should  be  steadied  with  one 


94  NORMAL   PREGNANCY 

hand  and  the  stethoscope  pressed  firmly  upon  it  ;  while 
listening  to  the  sound  the  mother's  pulse,  wdth  which  it  is 
synchronous,  should  be  felt  at  the  WTist.  There  is  some 
dispute  as  to  the  causation  of  the  uterine  souffle,  but  in  all 
probabihty  it  is  produced  in  the  greatly  enlarged  uterine 
arteries,  which,  it  will  be  remembered,  reach  the  laterpJ 
borders  of  the  organ  from  the  broad  ligaments  at  the  level  of 
the  internal  os.  Some  authorities  beheve  that  it  is  pro- 
duced in  the  large  maternal  vessels  of  the  placental  site  and 
that,  accordingly,  the  part  of  the  uterus  over  which  the  sound 
is  loudest  is  to  be  regarded  as  the  placental  site.  Apart  from 
pregnancy,  it  may  be  heard  in  cases  of  fibroid  tumours  of  the 
uterus. 

Foetal  Heart. — The  recognition  of  the  sounds  of  the  foetal 
heart  is  the  most  conclusive  of  all  the  signs  of  pregnancy  ; 
not  only  is  it  important  in  diagnosis,  but  during  labour  it 
affords  valuable  information,  and  the  student  should  lose  no 
opportmiity  of  becoming  famihar  mth  it.  The  foetal  heart 
can  usually  be  heard  by  the  twenty-sixth  week,  but  the 
further  pregnancy  advances  beyond  this,  the  more  easily  it  is 
detected.  Its  locahsation  at  this  period  is  variable,  and  the 
whole  anterior  surface  of  the  uterus  niust  often  be  carefully 
searched  before  it  can  be  found.  Some  experience  in  auscul- 
tation is  of  course  necessary ;  but  if  opportunities  of  learning 
this  sign  in  pregnant  women  at  term  have  been  previously 
made  use  of,  its  recognition  at  this  period  of  pregnancy  will 
be  greatly  facilitated.  At  the  sixth  month  the  foetal  heart- 
sounds  resemble  the  feeble  or  distant  ticking  of  a  watch ; 
they  are  much  more  rapid  than  the  beats  of  the  mother's 
pulse,  which  should  always  be  simultaneously  counted  as  a 
control,  and  they  differ  absolutely  in  character  from  the 
uterine  souffle.  When  for  any  reason  the  maternal  pulse 
rate  is  above  100  it  is  essential  that  a  defmite  difference  in 
rate  between  the  maternal  pulse  and  what  is  taken  for  the 
foetal  heart  should  be  clearly  made  out,  for  sounds  may  be 
transmitted  from  the  aorta  which  mil  be  misunderstood 
unless  this  precaution  be  taken.  At  the  sixth  month  the 
foetal  heart  beats  from  140  to  160  times  a  minute,  and  it  is 
therefore  difflcult  to  comit.  At  term  the  average  rate  is  from 
120  to  140,  but  even  wider  Umits  than  these  are  possible  ; 
only  when  the  rate  falls  below  100,  or  rises  above  160,  can 


DIAGNOSIS  95 

it  be  said  to  indicate  danger  to  the  fcBtus.  The  foetal  heart- 
rate  is  not  a  rehable  indication  of  sex.  It  has  been  generally 
believed  that  the  weight  of  the  foetus  affects  the  heart-rate, 
and  that  the  larger  the  foetus  the  slower  is  the  rate  ;  but 
recent  observations  by  Fieux  show  that  there  is  no  definite 
relation  between  weight  and  pulse-rate. 

In  connection  with  the  foetal  heart-sounds  the  funic 
souffle  must  be  mentioned.  It  sometimes  happens  in  auscul- 
tating the  gravid  uterus  that  a  loop  of  the  umbilical  cord  lies 
immediately  beneath  the  bell  of  the  stethoscope,  and  being 
subjected  to  slight  compression,  either  by  its  position  in  the 
uterus  or  by  the  instrument,  a  faint,  rapid,  blowing  murmur 
is  produced,  which  is  synchronous  with  the  foetal  heart- 
sounds.  It  is  seldom  detected,  and,  as  it  requires  accidentally 
favourable  circumstances  for  its  production,  it  is  of  no 
practical  importance. 

The  vaginal  ivalls  at  this  period  are  distinctly  softened  ; 
blue  discoloration  and  softening  of  the  cervix  are  more  dis- 
tinctly recognisable  than  at  earlier  periods.  Since  abdominal 
examination  yields  positive  signs  of  pregnancy,  from  this 
period  onwards  vaginal  examination  is  unimportant  for 
purposes  of  diagnosis. 

Thirty-sixth  week.- — ^The  shape  of  the  abdomen  and  the 
size  of  the  uterus  are  indicated  in  Fig.  50.  The  individual 
parts  of  the  body  of  the  foetus  can  now  be  recognised  by 
abdominal  palpation,  and  the  position  of  the  head,  back,  and 
limbs  localised.  This,  however,  is  of  little  importance  in  the 
diagnosis  of  pregnayicy,  but  attention  will  be  again  directed 
to  it  in  the  section  dealing  with  labour  (see  p.  342).  About 
the  thirty-sixth  week  the  uterus  attains  its  greatest  height  in 
the  abdomen,  extending  nearly  to  the  xiphoid  cartilage,  and 
the  maximum  abdominal  girth  averages  32  inches  ;  during 
the  last  fortnight  of  pregnancy  it  may  sink  to  a  point  mid- 
way between  the  umbilicus  and  the  xiphoid  cartilage,  and 
the  shape  of  the  abdomen  is  in  consequence  a  little  altered 
(Fig.  50).  Numerous  recent  striae  are  found  below  the 
umbilicus,  which  is  now  flat  or  slightly  everted. 

Determination  of  the  Period  to  which  Pregnancy  has 
Advanced. — This  is  sometimes  a  matter  of  considerable  diffi- 
culty, yet  its  practical  importance  is  great.  The  most 
reliable  guide  is  the  calculation  of  the  interval  which  has 


96  NORMAL   PREGNANCY 

elapsed  since  the  last  menstrual  period.  Where  these  data 
cannot  be  obtained  the  date  at  which  quickening  occurred 
may  be  obtainable,  and  tliis  may  be  taken  as  about  the 
sixteenth  week.  In  the  absence  of  both  these  guides  the 
height  of  the  uterus  above  the  pubes  is  the  only  other  criterion 
of  calculation.  Tliis  is  necessarily  inexact  and  variable, 
and  in  estimating  pregnancy  by  this  method  there  are 
several  obvious  sources  of  fallacy  to  be  borne  in  mind.  Thus 
there  are  individual  differences  in  the  thickness  of  the 
abdominal  parietes,  the  amount  of  hquor  amnii,  the  size  of 
the  foetus,  and  the  stature  of  the  mother.  The  size  of 
the  uterus  is  dependent  to  a  great  extent  upon  the 
amount  of  hquor  amnii  which  is  present ;  deficiency  is 
associated  with  an  unduly  small,  excess  with  an  unduly  large 
uterus.  In  tmn  pregnancy  the  uterus  is  also  unduly  large. 
Certain  conditions  make  the  uterus  apparently  larger  than  it 
should  be  ;  thus  contraction  of  the  pelvis  may  prevent  the 
foetus  from  sinking  into  the  pelvic  brim  towards  the  end 
of  pregnancy,  and  so  occasion  an  increased  height  of  the 
uterus  ;  a  tumour  lying  in  the  pelvis  would  produce  a  similar 
effect.  The  most  useful  rule  is  that  worked  out  by  Mac- 
donald,  who  fomid  that  after  the  twenty-sixth  week  the 
height  of  the  fmidus  above  the  symphysis  in  centimetres, 
divided  by  3 '5,  gives  the  number  of  lunar  months  of 
pregnancy.  Thus,  if  the  height  is  30  cm.  (12  inches),  the 
period  of  pregnancy  is  eight  and  a  half  months  =  thirty- 
four  weeks. 

Differential  Diagnosis  of  Pregnancy. — To  consider  aU  the 
varieties  of  abdominal  sweUings  which  may  be  mistaken  for  a 
pregnant  uterus  would  require  a  wdde  excursion  into  the 
domain  of  gynaecology,  and  cannot  be  midertaken  here.  It 
is,  however,  necessary  to  recall  the  occasional  occurrence  of 
a  curious  imitation  of  pregnancy  of  hysterical  origin  which 
is  kno^Ti  as  Pseudocyesis  (spurious  pregnancy).  It  occurs  in 
women  of  neurotic  temperament,  especially  when  associated 
\\ith  either  dread  of  pregnancy,  as  in  the  unmarried,  or  desire 
to  become  pregnant,*  as  in  sterile  married  women.  Such 
women  present  the  symptoms  of  amenorrhoea,  morning  sick- 
ness, and  progressive  abdominal  enlargement  ;  they  quicken, 
and  feel  what  they  regard  as  continual  and  active  foetal  move- 
ments ;    and  at  the  appointed  time  they  suffer  from  severe 


TWINS  y? 

and  prolonged  abdominal  pains  which  they  are  convinced 
represent  labour,  but  which  of  course  have  no  result.  On 
physical  examination  certain  signs  of  mammary  activity  may 
be  found,  which  are  undoubtedly  deceptive.  The  abdominal 
enlargement,  however,  will  seldom  deceive  any  but  the  most 
inexperienced  practitioner  ;  none  of  the  positive  signs  of 
pregnancy  can  be  detected  either  by  abdominal  or  vaginal 
examination  ;  and  if  an  anaesthetic  is  administered  the 
abdomen  becomes  flattened  (unless  the  patient  is  very  obese), 
and  bi-manual  examination  will  demonstrate  that  the  uterus 
is  not  enlarged. 

Multiple  Pregnancy 

While  it  is  the  rule  in  the  human  species  for  only  one 
child  to  be  born  at  a  birth,  twin  pregnancy  occurs  in  the 
proportion  of  about  1-80  to  1-90  births  ;  but  its  frequency 
varies  greatly  in  different  countries.  Heredity  is  the  only 
known  factor  in  causation,  and  the  influence  of  this  factor  is 
very  marked.  Triplets  are  very  much  less  frequent  than 
twins,  and  are  estimated  to  occur  only  once  in  6,000  to  10,000 
pregnancies.  Quadruplets  are  still  less  common  ;  although 
they  may  reach  the  period  of  viability  and  be  born  ahve,  they 
seldom  all  survive.  Quintuple  pregnancy  is  extremely  rare, 
and  always  ends  in  abortion.  A  recent  instance  has  been 
recorded  by  Nijhoff,  who  in  addition  succeeded  in  collecting 
twenty-seven  recorded  cases  of  quintuplets  in  obstetrical 
literature  between  1694  and  1900,  which  sufficiently  indicates 
the  great  rarity  of  the  condition. 

Twin  Pregnancy  may  result  from  the  simultaneous  fer- 
tilisation of  two  ova,  or  from  the  fertilisation  of  a  single  ovum; 
the  former  are  called  binovular,  the  latter  uniovular  twins. 
Binovular  twins  may  result  from  the  fertihsation  of  an  ovum 
from  two  distinct  Graafian  follicles,  or  of  two  ova  from  a 
single  folhcle.  Sometimes  two  follicles  ripen  simultaneously 
in  one  ovary.  The  ova  may  both  develop  in  the  normal 
uterus,  or  one  in  each  half  of  a  double  uterus  ;  or  one  in  the 
uterus,  the  other  in  a  Fallopian  tube  ;  or  one  in  each  Fallo- 
pian tube.  They  are  much  more  frequent  than  uniovular 
twins,  the  proportion  being  about  6  to  1 .  We  can  only  specu- 
late upon  the  manner  in  which  uniovular  twins  are  produced. 

E.M.  7 


98 


NORMAL  PREGNANCY 


The  ovum  may  possess  two  germinal  vesicles  (nuclei)  ;  or 
two  embryonic  areas  may  be  formed  if  an  ovum  is  fertilised 
by  more  than  one  spermatozoon  ;  or  the  single  embryonic 
area  may  divide,  each  half  producing  a  foetus.  Differences 
between  binovular  and  uniovular  twins  are  to  be  found  in 
sex,  in  development,  and  in  the  formation  of  the  placenta  and 
membranes.  In  each  variety  hydramnios  of  one  ovum  may 
occur,  the  other  remaining  normal. 

Sex. — Uniovular  twins  are  always  of  the  same  sex  ;  bin- 
ovular twins  may  be  of  the  same  or  of  different  sex,  the  latter 
being  rather  more  common  than  the  former.  Therefore  twins 


Fig.  51. — Twin  Placente  and  Membranes  of  Binovular  Development. 
(Eibemont-Dessaignes  and  Lepage.) 


of  the  same  sex  may  be  developed  either  from  one  or  two 
ova,  while  those  of  different  sex  are  necessarily  binovular. 
Including  all  cases,  twins  are  more  commonly  of  the  same  sex 
(boy  and  boy,  or  girl  and  girl)  than  of  different  sex,  and  as 
in  single  pregnancy  the  number  of  boys  exceeds  that  of  girls. 
Development. — A  twin  foetus  is  usually  somewhat  smaller  and 
lighter  than  a  single  foetus  ;  the  two  are  frequently  unequal 
in  size,  and  differences  of  1  to  Ih  pounds  in  weight  are  not 
uncommon.  One  may  be  normally  developed,  the  other 
malformed  ;  or  one  may  perish  during  pregnancy  while  the 
other  develops  tiU  term.  Malformations  are  common  with 
umovular  twins,  and  certain  rare  forms  of  monstrosity  only 


TWINS 


99 


occur  in  such  foetuses.  Placenta  and  Membranes . — With 
binovular  twins  the  two  ova  may  develop  quite  separately 
from  one  another,  so  that  two  separate  placentae  and  two 
complete  sets  of  membranes  are  formed  (Fig.  51).  If, 
however,  the  two  ova  should  be  implanted  close  to  one  another 
in  the  uterus,  the  two  placentae  will  be  in  contact,  and  they 
may  even  become  more  or  less  firmly  united  by  their  adjacent 
edges,  forming  apparently  a  single  organ.  The  decidua 
capsularis  then  forms  a  single  envelope  for  the  two  ova,  so 
that  the  two  chorions  are  apposed  where  the  ova  come  in 
contact.     The   circulatory   system   of   each  foetus  is   quite 


Fig.  52. — Twin  Placentae  and  Membranes  of  Uniovular  Development. 
(Ribemont-Dessaignes  and  Lepage.) 

distinct,  even  when  the  placentae  are  thus  united  ;  anasto- 
moses never  occur.  With  uniovular  twins  a  single  placenta 
and  chorion  are  formed  ;  the  amnion  may  be  double  (Fig.  53) 
or  single  (Fig.  52),  the  septum  in  the  former  being  fre- 
quently incomplete  at  term.  Usually  the  umbilical  cords 
are  distinct  ;  sometimes  the  cord  is  single  at  its  placental 
insertion,  but  bifurcates  before  reaching  the  foetuses. 
Free  anastomoses  always  exist  in  the  placenta  between  the 
circulatory  systems  of  the  two  foetuses,  and  according  to 
Schatz  this  is  usually  arterial,  but  may  rarely  be  venous  ; 
venous  anastomoses  (placental)  are  superficial,  arterial 
anastomoses  are  deep.     As  a  result  of  these  anastomoses 

7—2 


100 


XORMAL   PREGNANCY 


blood  from  one  foetus  finds  its  way  into  the  cii'culation 
of  the  other — an  important  factor  in  the  production  of  cer- 
tain foetal  monstrosities.  One  foetus  may  also  have  at  its 
disposal  a  larger  placental  area  than  the  other,  the  one  thus 
favoured  being  always  the  more  fully  grown.     Such  mon- 


Septum  (amniotic) 


Fig.  53. — Twin  Pregnancy  (probably  Uniovular)  ;  Abortion  at  Thii'd  to 
Fourth  Month.  The  Amnion  is  double.  (Charing  Cross  Hospital 
Museum.) 

Xote  that  torsion  has  occurred  in  the  umbilical  cords. 


strosities  as  the  thoracopagus  are  only  possible  in  twins 
of  uniovular  development. 

Recent  observations  upon  the  development  of  the  amnion 
make  it  probable  that  twin  foetuses  with  a  single  amnion  or 
with  united  umbilical  cords  are  developed  by  division  of  an 
originally  single  embryonic  area,  for  the  amniotic  vesicle  is 
clearly  seen  at  a  time  when  the  embryonic  area  is  repre- 
sented merely  by  a  thickened  laj^er  of  ectodermal  cells. 

Siiperfecundation  and  SuperfcEtation. — If    two    ova    are 


TWINS  101 

fertilised  simultaneously,  twin  pregnancy  results  ;  some- 
times a  second  ovum  is  fertilised  while  the  first  is  developing, 
and  to  this  condition  the  above  terms  are  applied.  If  the 
interval  between  the  two  separate  acts  of  fertilisation  is  a 
short  one,  the  condition  is  caUed  superfecundation  ;  instances 
are  well  known  to  occur  in  lower  animals,  as  when,  for 
example,  a  mare  gives  birth  to  a  horse  and  a  mule  at  a  single 
labour,  having  been  covered  at  about  the  same  time  by  a 
stallion  and  an  ass.  Proof  of  its  occurrence  is  difficult  in 
the  human  subject,  and  unless  the  foetuses  are  of  different 
colour  it  is  indistinguishable  from  binovular  twin  pregnancy. 
When  the  interval  between  the  two  acts  of  fertilisation 
is  considerable,  amounting  to  weeks  or  even  months,  the 
condition  is  called  superfostation.  If  ovulation  continues 
during  early  pregnancy,  there  is  no  insuperable  obstacle  to 
the  fertilisation  of  a  second  ovum  and  its  lodgment  in  the 
uterine  cavity,  so  long  as  the  decidual  space  persists — i.e., 
up  to  the  fourth  month.  The  result  of  this  occurrence  would 
be  the  presence  in  the  uterus  of  two  foetuses  of  different 
stages  of  development.  It  is  easy  to  conceive  of  such  an 
occurrence  in  the  Fallopian  tubes  or  at  any  period  of  preg- 
nancy in  a  double  uterus.  Superfoetation  may  end  in 
abortion,  both  ova  being  thrown  off  before  they  are  viable  ; 
or  one  ovum  developing  to  full  time,  a  mature  foetus  and  a 
premature  one  may  be  born  at  the  same  labour  ;  or  the  birth 
of  a  mature  foetus  may  be  followed  after  an  interval  of  a  few 
weeks  by  the  birth  of  a  second  equally  mature. 

Clinical  Course  of  Twin  Pregnancy. — Diagnosis  is  impos- 
sible during  the  early  months  ;  it  can  only  be  established  by 
the  detection  in  the  uterus  of  two  foetuses.  The  uterus  is 
always  larger  than  normal,  bat  undue  enlargement  must 
not  be  attributed  to  twins  without  more  definite  evidence. 
The  surest  sign  is  the  recognition  of  two  distinct  foetal 
hearts,  beating  at  different  rates.  This  sign  cannot  be 
detected  until  after  the  sixth  month,  and  unusual  care  must 
be  exercised  in  establishing  the  difference  in  rate  between 
the  two  hearts.  It  is  not  sufficient  for  the  observer  to  find 
foetal  hearfc-sounds  audible  at  two  different  parts  of  the 
uterus,  for  rapid  changes  in  the  position  of  the  foetus  may 
occur,  and  thus  lead  to  mistakes.  Two  observers  auscul- 
tating at  the  same  moment  should  simultaneously  count  the 


102 


NORMAL  PREGNANCY 


fcBtal  heart-sounds  to  which  they  are  Hstening,  and  if  a 
definite  difference  of,  say,  ten  beats  per  minute  is  detected 
between  them,  twins  may  safely  be  diagnosed.  This  differ- 
ence in  rate  is  believed  to  depend  upon  inequaUty  in  size 
of  the  foetuses  ;    but  if  there  is  only  slight  inequaUty  there 

will  be  no  recognisable 
difference  in  rate.  To- 
wards the  end  of  preg- 
nancy the  presence  of  a 
foetal  head  may  some- 
times be  definitely  recog- 
nised both  at  the  fundus 
and  in  the  lower  uterine 
segment.  Twin  preg- 
nancy is  frequently 
compUcated  with  hy- 
dramnios,  and  this  con- 
dition greatly  increases 
the  difficulty  of  diagnosis 
by  obscuring  the  results 
both  of  palpation  and 
auscultation. 

Twin  pregnancy  usu- 
ally ends  a  httle  before 
term  ;  that  is  to  say, 
labour  is  premature. 
Omng  to  the  undue  size 
of  the  uterus,  pressure 
symptoms  may  be  un- 
usually troublesome,  and 
morning  sickness  is  said 
to  be  often  unusually 
severe.  Sometimes  the 
uterus  is  not  much  larger 
than  normal ;  this  may  be  due  to  the  fact  that  one  foetus 
has  perished  in  utero.  When  this  occurs  the  fluid  in  the  dead 
ovum  is  absorbed,  and  the  body  of  the  foetus  compressed 
between  the  growing  ovum  and  the  uterine  wall,  and  its 
tissues  altered  by  absorption  of  fluid  ;  the  result  is  the  birth 
of  a  curiously  flattened  mummified  foetus,  to  which  the  term 
foRtus  papyraceus   or  fostus   compressus   has   been   applied 


Fig 


54. — ^Mummified    Foetus   (Foetus 
papji'aceus). 
(Charing  Cross  Hospital  Museum.) 


TRIPLETS 


103 


(Fig.  54).  The  placenta  of  this  foetus  offers  a  striking  con- 
trast with  that  of  the  hving  one  ;  it  is  pale,  and  completely 
consolidated  on  section,  no  trace  of  the  normal  spongy  tissue 
remaining.  Microscopically  it  presents  the  appearances 
characteristic  of  advanced  infarction  and  fatty  degeneration. 
Triplets  result  from  the  fertihsation  of  three  separate  ova 
or  from  the  occurrence  of  uniovular  twins  with  an  ordinary 


Placenta 
auccenturiata 


Fig.  55. — Triplet  Placenta  developed  from  Two  Ova,  and  showing  the 
Abnormality  of  Placenta  succenturiata.  (Eibemont-Dessaignes  and 
Lepage.) 


single  foetus.  In  the  former  case  three  distinct  placentae  and 
sets  of  membranes  are  found  ;  in  the  latter  and  commoner 
case  there  are  two  placentae  of  very  unequal  size,  the  larger 
having  two  cords  attached,  and  corresponding  to  the  placenta 
of  uniovular  twins  (Fig.  55).  The  single  foetus  may  have  a 
distinct  set  of  membranes.  Triplets  are  more  commonly  of 
different  sex  than  all  of  the  same  sex,  but  boys  predominate 
considerably  in  number.     Diagnosis  is  very  difficult,  and 


104  NORMAL  PREGNANCY 

labour  usually  comes  on  prematurely.     The  survival  of  all 
three  infants  is  rare. 

The  Management  of  Normal  Pregnancy 

Although  pregnancy  is  a  normal  bodily  function,  and 
should  not  be  regarded  as  a  malady,  it  is  undoubtedly 
attended  by  many  risks,  and  it  involves  a  considerable  strain 
upon  certain  organs,  which  they  may  be  miable  to  bear 
unless  care  is  taken  to  maintain  them  in  a  condition  of 
normal  physiological  activity.  This  is  especially  the  case 
in  a  first  pregnancy  ;  afterwards  the  organism  appears  to  be 
able  to  bear  with  less  disturbance  the  altered  conditions 
involved  in  the  pregnant  state.  The  functions  which  require 
the  closest  attention  are  those  of  digestion  and  excretion,  for 
their  failure  may  involve  the  most  serious  consequences  both 
to  the  mother  and  the  child.  Diet  is  a  matter  of  some  impor- 
tance during  pregnancy.  Generally  speaking  the  appetite 
is  increased  above  what  is  normal  to  the  individual,  and 
over-feeding  is  not  called  for  when  the  conditions  are  normal. 
Dietetic  fancies  quite  foreign  to  the  normal  tastes  of  the 
individual  are  sometimes  met  with,  the  so-called  '  longings,' 
and  these  need  not  be  discouraged  if  the  direction  they  take 
is  not  unwholesome.  Food  should  be  simple  and  plainly 
cooked  ;  meat  should  be  taken  only  in  moderate  quantities, 
and  sugar  or  sugar-containing  foods  should  be  reduced  even 
more  than  animal  proteids.  Fluids  should  be  taken  freely, 
and  the  value  of  milk  in  such  a  diet  is  sufficiently  obvious. 
Alkaline  natural  waters,  such  as  those  of  Vichy  or  Contrexe- 
ville,  are  useful.  The  waste  of  phosphates  and  chlorides 
which  occurs  during  pregnancy  should  be  borne  in  mind,  and 
lime  salts  in  the  form  of  phosphates  or  glycerophosphates 
are  useful.  The  tendency  to  anaemia  must  not  be  lost  sight 
of,  and  administration  of  iron  is  especiallj^  useful  in  the  early 
months.  Exercise  is  necessary,  but  should  not  be  violent 
or  attended  by  risk  of  accident,  which  may  result  in  abortion. 
The  more  energetic  forms  of  outdoor  exercise  should  there- 
fore be  avoided,  but  walking  is  useful  at  all  periods.  If  for 
any  reason  exercise  cannot  be  taken,  daily  massage  of  the 
limbs  and  back  forms  a  useful  substitute  for  it. 

Few,  if  any,  of  the  ordinary  symptoms  of  pregnancy 


MANAGEMENT  105 

require  treatment.  If  morning  sickness  is  troublesome  the 
patient  should  take  her  first  meal  before  rising,  preceded  by 
a  mild  aperient,  such  as  a  seidlitz  powder,  or  a  dose  of  Apenta 
water.  If  nausea  continues  during  the  day,  alkaline 
remedies,  such  as  the  salts  of  bismuth,  soda,  and  magnesia, 
are  useful.  During  the  later  months  pressure-symptoms  are 
often  much  relieved  by  wearing  a  well-fitting  abdominal  belt. 
The  urine  should  always  be  examined  at  least  once  in  the 
first  three  months,  and  a  regular  monthly'analysis  should  be 
made  during  the  second  half  of  pregnancy,  on  account  of  the 
liability  to  the  appearance  of  albuminuria  at  this  time.  This 
is  of  especial  importance  in  a  primigravida.  Success  in 
treating  this  serious  complication  depends  entirely  upon  its 
early  recognition. 

Examination  of  the  gravid  uterus  during  the  early 
months  of  pregnancy  is  unnecessary,  and  should  be  avoided 
unless  required  for  purposes  of  diagnosis.  It  should  then 
be  made  with  care  and  gentleness,  for  a  rough  internal 
examination  may  cause  a  miscarriage.  When  the  examina- 
tion is  made  under  anaesthesia  there  is  especial  need  for 
caution,  as  an  undue  amount  of  force  may  then  uncon- 
sciously be  used,  in  the  absence  of  any  check  from  the 
sensations  of  the  patient.  A  complete  physical  examination 
should,  however,  always  be  made  at  about  the  thirtieth 
week  to  determine  (1)  the  presentation  and  position  of  the 
child  ;  (2)  the  relation  between  the  size  of  the  head  and  that 
of  the  pelvic  brim  ;  (3)  the  condition  of  the  bony  and  soft 
maternal  passages  ;  (4)  the  presence  and  rate  of  the  foetal 
heart-sounds.  The  importance  of  determining  these  points 
well  in  advance  of  term  will  be  made  clear  in  the  section 
dealing  with  the  management  of  labour.  The  examination 
of  presentation  and  position  should  be  repeated  two  or  three 
weeks  before  labour  is  due. 

During  the  latter  half  of  pregnancy  the  nipples  must  be 
prepared  for  suckling  in  the  manner  described  on  p.  561. 


Part  II 

ABNOKMAL   PEEGNANCY 

Although  pregnancy  is  not  a  disease,  but  a  normal 
function  of  the  body,  there  is  no  doubt  that  a  pregnant 
woman  is  exposed  to  many  serious  risks  which  are  pecuhar 
to  her  condition,  while  certain  maladies  to  which  all  women 
are  liable  are  of  increased  gravity  when  associated  with  the 
pregnant  state.  In  addition,  morbid  conditions  primarily 
affecting  the  ovum,  are  met  with  which  destroy  it  and  lead 
to  its  premature  expulsion.  The  pathology  of  pregnancy 
thus  assumes  very  large  proportions,  and  comes  to  embrace 
a  great  number  of  morbid  conditions  which  may  affect  the 
mother,  the  embryo,  or  the  foetus  and  its  appendages.  In 
order  to  make  the  subject  intelhgible,  and  capable  of  being 
dealt  with  briefly,  classification  is  required,  but  a  practical 
classification  is  by  no  means  easy  to  devise.  A  simple 
division  into  the  main  groups  is,  however,  easily  made  ;  for 
while  some  of  the  conditions  included  are  abnormal  develop- 
ments of  pregnancy,  i.e.,  conditions  necessarily  associated 
with  the  pregnant  state,  in  the  case  of  others  the  association 
with  pregnancy  is  only  accidental.  The  jfirst  group  we  may 
call  The  Disorders  of  Pregnancy,  for  pregnancy  is  the 
essential  factor  in  their  causation.  As  examples  may  be 
mentioned  the  disease  called  eclampsia,  and  the  hydatidiform 
mole  (vesicular  degeneration  of  the  chorion)  ;  none  but 
pregnant  women  suffer  from  these  diseases  and  their  many 
consequences,  and  they  are  directly  due  to  some  disturbance 
of  the  normal  course  of  pregnancy.  The  second  group  we 
may  call  The  Disorders  associated  with  Pregnancy  ; 
they  may  have  been  in  existence  before  conception  occurred 
and  have  become  aggravated  by  pregnancy,  such  as  valvular 
disease  of  the  heart  ;  or  they  may  arise  during  the  course  of 
pregnancy  and  interrupt  it,  hke  the  acute  eruptive  fevers. 
Instead  of  subdividing  the  first  group  into  foetal  and  maternal 


CLASSIFICATION  107 

disorders,   as  is  usually  done,   we   shall  classify  them   as 
follows  : 

I.  Disorders  of  Pregnancy 

Toxcemias. 

(1)  Albuminuria  and  Eclampsia. 

(2)  Pernicious  vomiting. 

(3)  Ptyalism.* 

(4)  Pruritus.* 

(5)  Herpes.* 

(6)  Mental  disturbances.* 

Abnormal  Conditions  of  the  Gravid  Uterus. 

(1)  Displacements. 

(2)  Malformations. 

Pressure-symptoms. 

(1)  (Edema. 

(2)  Varicose  veins. 

(3)  Haemorrhoids. 

Abnormal  Conditions  of  the  Ovum. 

(1)  The  Early  Ovum. 

{a)  Moles, 
i.  Blood  mole — Fleshy  mole  (hsematoma  mole), 
ii.  Hydatidiform  mole  (vesicular  degeneration  of 
chorion). 
(6)  Decidual  endometritis. 

(2)  Placenta  and  Membranes, 
{a)  Oligo-hydramnios. 

(b)  Poly-hydramnios. 

(c)  Placental  diseases. 

QEdema. 

Fatty  degeneration. 

Haemorrhage. 

New-growths. 

Syphilis. 

Tubercle. 

Infarction. 

Abnormal  Implantation  of  the  Ovum. 
Ectopic  gestation. 

*  Provisionally  classed  as  toxeemias. 


108  ABNORMAL   PREGNANCY 

II.   Disorders  associated  with  Pregnancy 

{a)  Acute  eruptive  fevers. 
(6)  Sjrphilis  and  tubercle. 

(c)  Cardiac  disease. 

(d)  Renal  disease. 

Bright 's  disease  ;   bacillus  coli  infection. 

(e)  Hepatic  disease. 

Acute  yellow  atrophy  ;   diabetes. 
(/)   Diseases  of  the  nervous  system. 

Chorea. 
{g)  Pelvic  diseases. 

Ovarian  and  uterine  tumours. 

Gonorrhoea. 

Toxemias  oe  Pregnancy. 

Before  proceeding  to  consider  individually  the  disorders 
which  are  included  in  this  gr®up,  there  are  certain  general 
considerations  applicable  to  them  all  which  must  be  referred 
to.  Thus  we  must  first  consider  what  reasons  we  have  for 
regarding  them  as  toxaemic  in  origin,  and  also  what  is  known 
or  surmised  as  to  the  nature  and  source  of  the  toxaemia. 

As  regards  the  first  point,  it  must  be  said  at  once  that 
direct  proof  of  their  toxsemic  origin  cannot  be  advanced,  and 
is  in  the  nature  of  the  case  practicable  only  by  the  actual 
discovery  of  the  toxic  body  or  group  of  bodies.  Nevertheless 
a  mass  of  evidence  based  upon  the  analogy  of  other  diseases 
known  to  be  toxsemic,  and  upon  scientific  inference,  has  been 
gradually  accumulated,  which  for  practical  purposes  amounts 
to  proof.  Post-mortem  changes  naturally  furnish  a  great 
part  of  the  evidence  required,  and  consequently  those  diseases 
which  tend  to  terminate  fatally  supply  the  best  opportunities 
for  studying  the  toxaemias  of  pregnancy.  Proof  of  their 
toxsemic  origin  is  accordingly  much  more  complete  in  the 
case  of  eclampsia  and  pernicious  vomiting  than  any  of  the 
others,  all  of  which  show  little  tendency  to  cause  death. 

The  post-mortem  changes  believed  to  be  characteristic  of 
death  from  toxaemia  will  be  fully  described  in  connection 
with  eclampsia.  It  may  be  stated  here  that  they  consist 
mainly  of  two  groups  ;  (a)  extensive  thrombosis,  and 
interstitial  haemorrhage  from  rupture  of  capillaries  ;    (6)  cell 


TOXEMIAS  109 

necrosis,  sometimes  scattered,  sometimes  affecting  large 
areas,  i.e.,  '  massive  necrosis.'  These  changes  are  widely  dis- 
tributed, and  while  the  liver  and  the  kidneys  are  the  organs 
mainly  affected,  to  a  less  extent  they  may  often  be  found 
in  many  others. 

In  addition  to  the  post-mortem  changes  certain  clinical 
evidences  of  toxaemia  may  also  be  forthcoming.  One  of  the 
most  important  is  to  be  found  in  modifications  of  nitrogen 
metabolism  and  of  carbohydrate  metabolism. 

In  health  the  urinary  excretion  of  nitrogen  takes  place 
through  the  following  substances  (Folin)  : 


Urea 

Ammonia 

Creatinin . 

Uric  Acid 

Undetermined  Nitroaren 


87*0  per  cent,  of  the  total  urinary  N. 
3-3 
2-7 

0-7        „ 
6-0 


In  toxsemic  conditions  the  proportions  of  these  substances 
are  substantially  modified  ;  the  amount  excreted  as  urea  is 
diminished,  while  the  amount  excreted  as  ammonia,  and  as 
'  undetermined  '  is  considerably  increased.  Three  per  cent, 
is  the  normal  ammonia-coefficient  of  N  excretion  ;  a  rise  in 
this  coefficient  is  an  indication  of  toxaemia.  The  analyses 
required  to  determine  these  changes  are  elaborate  and  costly, 
and  accordingly  the  determination  of  the  ammonia-coeffi- 
cient has  not  been  widely  made  use  of  except  by  expert 
pathological  chemists.  But  sufficient  work  has  been  done 
to  show  that  in  eclampsia  and  in  pernicious  vomiting  a  rise 
in  the  ammonia-coefficient  is  usually  found,  and  that  in  severe 
cases  it  may  reach  20  per  cent. 

There  are  certain  sources  of  fallacy  which  must  be 
guarded  against  in  applying  the  test ;  thus  severe  vomiting 
and  restriction  of  diet  both  occasion  a  moderate  rise  in  the 
NHg  coefficient,  probably  because  '  starvation  '  of  the  tissues 
results  in  an  excessive  production  of  tissue-waste  products, 
the  resulting  '  toxsemic  '  condition  being  aggravated  by  the 
coincident  failure  of  the  excretory  functions.  Within  recog- 
nised limits,  however,  the  test  is  a  useful  one. 

Carbohydrate  metabolism  is  also  profoundly  affected  in 
toxaemia,  especially  in  those  forms  which  are  associated  with 
persistent  vomiting.     This  is  shown  by  the  accumulation  in 


110  ABNORMAL   PREGNANCY 

the  blood  of  two  acid  substances,  viz.,diacetic  acid  and  ;8-oxy- 
butyric  acid  ;  along  with  them  acetone  is  also  always  found, 
but  the  presence  of  that  body  alone  is  not  of  great  clinical 
significance.  When  present  in  the  blood  in  great  excess  these 
substances  constitute  the  condition  known  as  'Acidosis,' one 
of  the  most  dangerous  toxsemic  conditions  with  which  we 
are  acquainted.  It  has  been  shown  that  in  severe  cases  of 
eclampsia  and  also  of  pernicious  vomiting  a  condition  of 
acidosis  usually  exists  ;  it  is  also  believed  to  be  the  cause 
of  diabetic  coma,  and  is  present  in  post-ansesthetic  chloro- 
form poisoning  such  as  sometimes  occurs  after  prolonged 
anaesthesia. 

In  all  probability  there  is  a  direct  connection  between 
acidosis  and  an  increased  ammonia-coefficient.  The  excess  of 
acid  in  the  blood  is  partly  neutralised  by  the  alkaline  salts 
of  the  blood  serum  ;  the  alkaline  base  of  the  blood  salts  is 
mainly  ammonia,  and  the  resulting  compounds  of  ammonia 
withdiacetic  acid  and  oxybutyricacid,  being  excreted  through 
the  kidneys,  tend  to  raise  the  ammonia-coefficient. 

The  organ  chiefly  concerned  in  carbohydrate  meta- 
boHsm,  and  in  the  final  stages  of  N  metabolism,  when  the 
innocuous  end-products,  such  as  urea,  are  produced,  is  the 
liver.  It  therefore  appears  that  derangement  of  the  liver  func- 
tions plays  an  important  part  in  the  production  of  toxaemia. 

Another  point  in  which  pregnancy  toxaemia  comes  into 
line  with  toxaemic  conditions  generally  is  that  there  is  a 
considerable  increase  of  lipoid  substances  in  the  blood, 
which  is  probably  to  be  regarded  as  another  indication  of 
derangement  of  the  hepatic  functions. 

Still  further  clinical  evidences  of  a  toxaemic  state  are  to 
be  found  in  elevation  of  blood  pressure,  fever,  diminution 
of  the  excretory  functions,  and  the  supervention  in  the  final 
stages  of  coma,  with  or  without  convulsions.  Occasionally 
haemorrhages  from  mucous  surfaces  occur,  and  in  rare 
instances  serious  bleeding  from  the  gastric  and  intestinal 
mucous  membranes  have  been  observed.  All  of  these 
symptoms  may  appear  in  serious  examples  of  pregnancy 
toxaemias. 

The  Nature  of  the  Toxic  Bodies. — Long  before  the  modern 
theory  of  toxaemia  was  foreshadowed,  clinical  observers  had 
thrown   out   the   suggestion   that   certain   of   the   diseases 


TOXEMIAS  111 

peculiar  to  the  pregnant  state  might,  perhaps,  be  due  to  the 
undue  accumulation  of  waste  products  in  the  maternal 
blood  derived  from  the  body  of  the  foetus,  and  coming 
through  the  umbilical  vessels.  They  imagined  an  adjust- 
ment, under  normal  conditions,  of  the  eliminatory  functions 
to  enable  them  to  cope  with  the  increased  output  of  waste 
products  necessitated  by  the  development  of  the  child  in 
the  uterus.  This  adjustment  might  conceivably  break 
down,  either  from  excessive  maternal  absorption  of  waste 
products  resulting  from  foetal  disease,  or  from  deficient 
elimination  produced  by  functional  or  structural  changes  in 
the  great  maternal  organs  of  excretion.  Recent  biological 
research  has  not  lent  support  to  the  theory  of  foetal  intoxi- 
cation as  conceived  by  clinical  observers  of  an  earlier  time. 
Further,  it  has  been  shown  that  toxaemia  of  the  gravest  kind 
may  occur  in  association  with  the  vesicular  mole  (p.  148),  in 
which  there  is  usually  no  foetus,  and  consequently  foetal 
metabolism  can  play  no  part. 

Recent  work  has  postulated  two  possible  sources  of 
toxaemia  in  pregnancy,  a  maternal  and  a  chorionic  ov  placental . 

The  maternal  theory  may  be  stated  as  foUows.  In  health 
the  waste  products  of  the  body  tissues  are  disposed  of 
either  by  direct  excretion  through  the  kidneys,  skin,  and 
intestines,  or  by  transformation  into  harmless  substances 
within  the  body  ;  the  organ  mainly  concerned  in  the  latter 
process  is  the  liver,  with  perhaps,  secondarily,  certain  duct- 
less glands  such  as  the  spleen,  the  thyroid,  and  the  suprarenal 
bodies.  In  normal  pregnancy,  although  an  excess  of  waste 
products  may  enter  the  maternal  blood  from  the  uterus  and 
ovum,  the  normal  channels  of  excretion  and  transformation 
suffice  for  their  removal,  although  evidences  of  derangement 
of  the  functions  of  the  liver  in  normal  pregnancy  have  been 
already  adduced.  In  addition,  indications  are  not  wanting 
that  certain  definite  alterations  in  the  general  metabolism 
of  the  body  also  occur  during  pregnancy  ;  although  their 
significance  is  not  at  present  clear,  they  must  be  regarded  as 
important  in  respect  to  the  delicate  balance  of  the  functions 
of  ingestion  and  elimination.  In  order  to  maintain  in  preg- 
nancy the  normal  equilibrium,  it  is  clearly  necessary  that 
all  the  maternal  organs^^  concerned  should  maintain  their 
functional  activity,  and  even  perhaps  increase  it  above  the 


112  ABNORMAL  PREGNANCY 

normal  level.  A  physiological  breakdown  on  the  part  of  im- 
portant organs  like  the  Hver  or  kidneys  must  necessarily  entail 
serious  consequences — much  more  serious  than  in  the  non- 
gravid  state — -and  accumulation  of  toxic  waste  products  of 
maternal  origin  in  the  blood  will  become  inevitable.  The 
organs  which  most  commonly  show  clinical  signs  of  failure 
diu'ing  pregnancy  are  the  kidneys,  and  this  failure,  as  we  shall 
see,  is  probably  accompanied  by  certain  pathological  changes 
in  the  renal  cortex.  But  the  view  that  the  kidnej^s  are  the 
organs  primarily  at  fault  cannot  be  maintained  ;  the  changes 
in  them  are  the  result  of  profound  biochemical  disturbances 
of  metabolism,  the  primary  cause  of  which  may  finally 
prove  to  be  different  in  different  morbid  conditions. 

The  maternal  theory  thus  regards  pregnancy  toxsemia  as 
an  auto-intoxication  due  to  a  breakdo^^ii  of  general  meta- 
bohsm  ;  one  of  the  first  results  of  this  auto-intoxication  is 
that  renal  changes  occur  which  profoundly  affect  urinary 
excretion,  and  thus  aggravate  the  toxeemic  condition. 

The  chorionic  or  2>lacental  theory  goes  much  further  than 
this,  and  attempts  to  indicate  the  actual  source  of  the  toxic 
bodies.  The  maternal  organism,  according  to  this  view,  is 
directly  poisoned  by  certain  elements  of  the  ovum.  These 
are  not  the  waste  products  of  the  body  of  the  foetus,  but  are 
derived  from  the  foetal  membranes.  The  parasitic,  toxic 
nature  of  the  portions  of  chorionic  epithehum  which  under 
normal  conditions  are  detached  and  enter  the  maternal  blood 
is  held  to  be  proved  by  Abderhalden's  test.  Toxaemia 
may  conceivably  result  from  a  failure  of  the  antibodies  to 
deal  effectively  with  these  s3Tic}i:ial  masses,  and  this  may 
be  due  to  the  presence  of  the  latter  either  in  abnormal 
quantity  or  in  altered  quahty. 

The  entrance  of  syncytium  into  the  maternal  blood  is 
mainly  found  in  the  early  months,  when  the  syncytium  is 
most  active  ;  in  the  later  months  it  is  much  less  marked. 
Schmorl  and  others  have,  however,  shown  that  in  eclampsia 
pulmonary  emboli  containing  small  chorionic  viUi  and 
masses  of  sjTicytium  are  not  uncommonly  found.  It  is, 
therefore,  possible  that  this  disease  is  accompanied  by  a 
renewed  active  penetration  of  maternal  vessels  by  the 
syncytium,  and  to  this  extent,  in  the  case  of  eclampsia,  post- 
mortem conditions  lend  support  to  the  placental  theory. 


TOXEMIAS  113 

Direct  intoxication  by  the  accumulation  of  syncytium 
in  the  blood  is  not  the  only  form  in  which  the  placental 
theory  may  be  stated.  It  is  possible  that  complex  toxic  bodies 
may  be  secreted  in  the  placenta  and  passed  thence  into 
the  maternal  circulation.  Many  attempts  have  been  made  to 
separate  such  toxic  bodies  from  the  placenta,  both  in  health 
and  in  disease,  but  no  conclusive  results  have  been  obtained. 
There  is,  therefore,  no  actual  proof  that  the  placenta  can 
elaborate  toxins.  Interesting  observations  bearing  upon 
this  point  have,  however,  been  recently  made  by  James 
Young.  This  observer  claims  to  have  shown  that  if  a 
placental  cotyledon  becomes  separated  from  the  uterine  wall 
by  haemorrhage,  massive  necrosis  of  the  separated  cotyledon 
ensues  ;  the  resulting  products  of  placental  autolysis  will 
freely  enter  the  maternal  blood,  and  he  suggests  that  such 
a  mass  of  necrotic  tissue  may  become  the  source  of  toxic 
bodies  capable  of  producing  either  eclampsia,  or  other  forms 
of  pregnancy  toxaemia.  This  view  imphes  that  retro - 
placental  or  retro-ovular  haemorrhage  causing  extensive 
placental  chorionic  necrosis  is  the  primary  cause  of  the 
toxaemia,  and  therefore,  without  it,  toxaemia  will  not  occur. 
Young's  observations  were  confined  to  cases  of  eclampsia, 
and  can  be  easily  tested  by  the  systematic  examination  of 
eclamptic  placentae. 

While  in  the  meantime  no  definite  conclusion  can  be 
reached,  it  must  be  said  that  the  weight  of  evidence  is 
strongly  in  favour  of  the  theory  of  the  placental  (chorionic) 
origin  of  pregnancy  toxaemias.  In  the  case  of  eclampsia 
the  evidence  is  stronger  than  in  the  case  of  any  of  the  other 
toxaemias. 

Albuminuria  and  Eclampsia 

Albuminuria  occurring  during  pregnancy  may  be  due  to 
{!)  pre-existing  renal  disease — e.g.,  chronic  nephritis  ;  (2)  preg- 
nancy. The  latter  is  spoken  of  as  '  the  albuminuria  of 
pregnancy,'  and  must  be  sharply  distinguished  from  the 
former  variety,  which  will  be  considered  in  the  group  of 
'  Disorders  associated  with  Pregnancy.'  Albuminuria  and 
eclampsia  must  be  considered  together  because,  although 
eclampsia  may  very  exceptionally  occur  without  albuminuria, 
E.M.  8 


114  ABNORMAL   PREGNANCY 

they  are  almost  invariably  associated.  This  association  is 
indeed  so  marked  that  the  conclusion  cannot  be  avoided  that 
they  are  due  to  one  and  the  same  cause.  It  must,  however, 
always  be  borne  in  mind  that  the  majority  of  cases  of  albu- 
minuria terminate  favourably  without  the  supervention  of 
eclampsia  ;  further,  it  cannot  be  said  that  the  higher  the 
degree  of  albuminuria  the  greater  is  the  risk  of  eclampsia. 

Strictly  speaking,  albuminuria  is  but  a  symptom,  and  in 
the  disease  which  is  conveniently  designated  '  the  albu- 
minuria of  pregnancy  '  other  clinical  features  of  great  impor- 
tance are  found  besides  the  presence  of  albumen  in  the  urine. 
We  must  be  careful,  therefore,  to  exclude,  in  addition  to  pre- 
existing renal  disease,  such  transient  causes  of  albuminuria, 
as  fatigue  and  dyspepsia,which  may  give  rise  to  it  temporarily 
in  any  circumstances.  Albumen  due  to  these  causes  only 
occurs  in  traces.  Contradictory  statistics  have  been  pub- 
lished as  to  the  frequency  with  which  albuminuria  is  to  be 
found  in  pregnant  women,  the  proportion  varying,  according 
to  different  observers,  from  3  to  50  per  cent.  The  highest 
rate  of  frequency  occurs  in  parturient  women,  and  there  is 
no  doubt  that  in  a  large  majority  of  primiparse,  and  in  a 
smaller  proportion  of  multiparse,  traces  of  albumen  occur  in 
the  urine  during  normal  labour,  and  disappear  at  once  when 
labour  is  over.  This  condition  does  not  concern  us  at  present 
but  will  be  referred  to  again  later  on.  Excluding  parturition, 
the  rate  of  frequency  of  albuminuria  in  pregnant  women 
probably  does  not  exceed  3  to  5  per  cent.,  and  from  this 
must  still  be  deducted  cases  of  pre-existing  renal  disease 
and  cases  of  transient  functional  albuminuria.  It  will  there- 
fore be  seen  that  the  disease  we  are  considering  is  fairly 
luicommon. 

Clinical  Features. — The  albuminuria  of  pregnancy  is 
practically  confined  to  the  latter  half  of  the  period  of  gesta- 
tion, and  seldom  manifests  itself  earlier  than  the  sixth  month 
(twenty-sixth  week),  although  cases  of  eclampsia  at  the  fifth 
month  have  been  recorded.  It  is  much  more  frequent  in 
primigravidse  than  in  multiparse.  Cases  differ  greatly  in 
severity  :  in  some  the  only  symptom  is  a  moderate  amount  of 
albumen  in  the  urme,  which  disappears  luider  treatment ;  or, 
even  when  persisting,  it  may  be  unaccompanied  by  other 
symptoms,  and  may  not  interrupt  the  development  of  the 


ALBUMINURIA  115 

ovum  or  the  course  of  the  pregnancy.  Every  case,  however, 
requires  careful  management,  for  the  risk  of  other  and  more 
serious  symptoms  supervening  is  always  present.  Thus 
albuminuria  is  frequently  accompanied  by  other  urinary 
changes,  and  by  anaemia  and  anasarca  ;  frequently  it  leads  to 
death  of  the  foetus  in  utero  and  the  occurrence  of  premature 
labour  ;  more  rarely  it  leads  to  the  occurrence  of  retinitis, 
or  terminates  in  convulsions  {eclampsia).  These  conditions 
must  now  be  considered  in  more  detail. 

Urinary  Changes. — In  the  earlier  stages  of  the  affection 
the  urine  is  abundant,  pale,  of  low  specific  gravity,  and  con- 
tains a  diminished  proportion  of  total  solids.  The  amount  of 
albumen  present  is  a  rough  indication  of  the  severity  of  the 
case.  There  may  be  but  a  trace  ;  usually,  however,  the 
amount  is  considerable  (Jq  to  |  per  cent.,  Esbach),  and  in  the 
worst  cases  of  all — viz.,  those  which  terminate  in  eclampsia — 
the  urine,  when  tested  during  the  eclamptic  seizures,  usually 
solidifies  on  boiling.  The  amount  of  albumen  is  not  in  itself 
a  reliable  index  of  the  liability  to  eclampsia,  for  many  cases 
with  a  heavy  albumen  output  terminate  without  convulsions. 
It  has  been  observed  that  a  large  proportion  of  the  albumen 
is  serum  globulin,  but  we  do  not  know  the  significance  of  this 
point,  and,  owing  to  technical  difficulties  in  estimation,  the 
exact  proportion  of  globulin  to  albumen  has  not  been  worked 
out  in  a  series  of  cases.  Of  more  importance  is  the  occur- 
rence of  casts  which  can  usually  be  found  ;  they  are  hyaline 
and  granular,  and  often  show  fatty  degeneration.  Red  and 
white  blood-corpuscles  are  also  occasionally  found.  The 
total  amount  of  urea  excreted  is  fairly  normal,  but  a  diminu- 
tion usually  occurs  in  connection  with  eclampsia,  and  a  fall 
in  the  output  of  urea  is  an  important  premonitory  sign  of 
this  complication.  When  anasarca  is  marked,  the  amount 
of  urine  excreted  becomes  scanty,  while  in  eclampsia  the 
secretion  is  very  scanty,  and  may  even  be  suppressed. 

Ancemia  and  Anasarca. — These  two  conditions  are  usually 
associated,  and  it  is  rare  to  find  one  marked  without  the 
other  being  almost  equally  so.  The  pallor  of  the  face  and 
mucous  membranes  forms  one  of  the  most  striking  features 
of  these  cases,  and  gives  rise  at  once  to  the  suspicion  of 
albuminuria.  The  anasarca  affects  chiefly  the  lower  extremi- 
ties, the  vulva,  and  the  abdominal  wall ;   it  is  said  to  occur 

8—2 


116  ABX0R]\L1L   PREGXAXCY 

also  in  the  face  and  upper  extremities,  but  with  such  a 
distribution  the  greatest  care  should  be  taken  to  exclude 
chronic  Bright"s  disease.  Clinical  experience  shows,  how- 
ever, that  cases  in  which  extensive  oedema  occurs  rarely 
develojD  eclampsia.  The  pre-eclamptic  state  is,  however, 
sometimes  attended  with  puffiness  of  the  eyehds.  The 
oedema  of  the  lower  extremities  may  be  extreme,  and  some- 
times the  labia  majora  become  greatly  enlarged,  so  as  to 
interfere  with  the  dilatation  of  the  vulva  durmg  labour.  It 
is  said  that  anasarca  may  occur  to  a  marked  degree  without 
albuminuria,  or  that  it  may  appear  first,  but  this  is  unusual. 

Death  of  the  Fcetus,  and  Premature  Labour. — A  heavy 
foetal  mortality,  probably  over  50  per  cent.,  attends  the 
albummuria  of  pregnancy.  It  is  largely  mdependent  of 
eclampsia.  The  foetus  perishes  in  utero,  and  the  ovum  is 
then  thrown  off,  either  at  once  or  within  a  few  weeks  ; 
amehoration  of  the  general  symptoms  sometimes  follows  the 
death  of  the  foetus,  even  when  it  is  retained  for  some  time 
in  the  uterus.  Often,  however,  a  Hving  premature  child  is 
born,  but  it  is  usually  undersized  and  feeble,  and  its  chance 
of  surviving  is  but  small.  Placental  disease  is  present  in  a 
considerable  proportion  of  these  cases,  and  appears  to  be 
an  important  factor  in  causing  the  death  of  the  foetus  and 
in  inducing  labour  prematurely.  This  disease  consists  in 
extensive  infarction  of  the  placental  substance — a  change 
which  will  be  again  referred  to  later  on  (see  p.  165). 

Eclampsia. — We  do  not  know  the  exact  proportion  of 
cases  of  albuminuria  which  terminate  in  eclampsia  ;  it  is 
probably  small.  But  eclampsia  is  by  no  means  confined  to 
cases  in  which  there  has  been  previous  clinical  evidence,  of 
longer  or  shorter  duration,  of  the  existence  of  albuminuria. 
Eclampsia  accompanied  by  albuminuria  may'  suddenly 
supervene  in  pregnant  women  who  have  jDreviousty  been  in 
apparently  good  health  ;  or  eclampsia  may  sometimes  come 
on  in  this  way  "^ith  no  attendant  albuminuria.  The  con- 
vulsions are  indistinguishable  in  their  general  characters  and 
course  from  those  of  uraemia,  and  the  differential  diagnosis 
from  the  former  may  present  insuperable  difficulties.  Some- 
times eclampsia  is  ushered  in  by  a  definite  pre-eclamptic 
stage,  the  cHnical  recognition  of  which  is  of  great  importance 
(see  p.  528).     Eclampsia  is  most  commonly  met  with  as  a 


ECLAMPSIA  117 

complication  of  labour,  and  the  consideration  of  its  clinical 
features  and  treatment  will  therefore  be  postponed  till  a 
later  section. 

Pathological  Anatomy  of  Eclampsia. — Cases  of  albu- 
minuria are  rarely  fatal  unless  complicated  with  eclampsia  ; 
the  pathology  of  the  albuminuria  of  pregnancy  has  therefore 
been  somewhat  difficult  to  elucidate,  but  abundant  evidence 


Degenerated   renal    epithelium 


Fig.  56. — Eenal  Tubules  from  a  Case  of  Eclampsia ;  Numerous  Fat 
Globules  occur  in  the  Degenerated  Cells.     (Hamilton  Bell.) 

has  now  been  accumulated  to  show  that  in  fatal  cases  of 
eclampsia  definite  morbid  changes  occur  in  the  liver  and 
kidneys,  and  a  further  series  of  changes  is  also  found  in  the 
sj)leen,  brain  and  other  organs. 

Kidneys  and  Ureters. — Definite  renal  changes  are  found  in 
99  per  cent,  of  autopsies  on  cases  of  eclampsia.  The  most 
important  changes  occur  in  the  renal  cortex,  and  they  are  of 
the  nature  of  degeneration,  not  inflammation.  The  whole 
kidney  is  enlarged,  the  cortex  swollen  and  pale  ;    the  pallor 


118  ABNORMAL  PREGNANCY 

(anaemia)  appears  to  be  due  to  vaso-motor  spasm  affecting  the 
cortical  arterioles.  Cloudy  swelling  with  granular  and  fatty 
degeneration  of  the  epithelial  cells  of  the  convoluted  tubules 
is  apparent  on  microscopical  examination  (Fig.  56).  Small 
interstitial  haemorrhages  and  areas  of  necrosis  are  also  found 
in  the  cortex,  and  thrombosis  is  often  present  in  the  capil- 
laries of  the  glomeruh.  These  changes  are  not  universal,  but 
occur  in  patches,  the  remainder  of  the  renal  substance  being 
healthy.  In  albuminuria  without  eclampsia  the  degenera- 
tive changes  occur,  but  not  the  areas  of  haemorrhage  and 
necrosis  ;  this  condition  is  often  called  the  i^regnancy  kidney. 
These  changes  are  transient,  and,  in  the  great  majority  of 
cases  that  recover,  they  disappear  rapidh^  after  labour,  but 
it  is  stated  that  the  condition  may  occasionally  pass  into 
true  parenchymatous  nephritis.  The  rapid  disappearance 
of  the  renal  changes  can  of  course  be  watched  by  observation 
of  the  urine  during  the  puerperium. 

In  a  certain  proportion  of  fatal  cases  of  eclampsia,  dilata- 
tion of  one  or  both  ureters  above  the  level  at  which  they  cross 
the  pelvic  brim  has  been  shown  to  occur,  and  some  writers 
have  estimated  its  frequency  as  one  in  five.  The  unfavour- 
able influence  of  this  change  upon  the  functional  activity, 
and  even  the  structure,  of  the  kidney  is  obvious.  It  is 
therefore  a  factor  of  importance  in  the  causation  of  albu- 
minuria, but  it  must  be  regarded  as  a  contributory,  not  an 
essential,  factor.  It  is  most  frequently  found  in  primi- 
gravidae,  and  may  be  occasioned  by  the  uterus  itself,  or  by 
direct  pressure  of  the  foetal  head  upon  the  ureter  ;  for  we 
know  that  in  the  last  two  to  three  months  of  pregnancy  the 
foetal  head  usually  occupies  the  pelvic  brim  in  primiparae. 

Liver. — Changes  in  this  organ  are  almost  invariably 
found  in  cases  of  eclampsia  ;  they  are  of  great  importance 
and  are  regarded  by  some  authors  as  lesions  specifically 
characteristic  of  this  disease.  To  the  naked  eye  haemor- 
rhages beneath  the  capsule  and  on  the  cut  surface  are  the 
most  constant  feature  ;  they  may  be  small  and  numerous, 
or  they  may,  by  fusion,  form  large  areas.  The  whole  organ 
may  be  enlarged  by  the  extent  of  these  haemorrhages  ; 
sometimes  it  is  small  and  resembles  the  liver  of  acute  yellow 
atrophy.  On  the  cut  surface  areas  of  ill-defined  outhne 
may  be  seen,  paler  than  the  surrounding  liver  substance. 


PL.iTE   III. 


(fl.)  Liver  from  a  Case  of  Eclampsia.  An  area  of  degeneration  in  the  periphery 
of  a  lobule  is  seen  in  the  upper  part.  An  area  of  total  disintegration  is 
seen  in  the  lowest  part.  In  some  parts  the  liver  cells  are  little  affected. 
(Pathology  Department  of  the  London  Hospital.) 


{h)  Liver  from  a  Ca^e  of  Toxasmic  Vomiting.  An  area  of  advanced  cell 
degeneration  is  seen  in  the  centre  ;  vacuolation  is  the  chief  feature.  These 
changes  were  widely  diffused  over  the  whole  organ.  (Pathology  Depart- 
ment of  the  London  Hospital.) 


HEPATIC  CHANGES  119 

which,  when  examined  microscopically,  appear  as  areas  of 
massive  necrosis. 

Microscopically  the  changes  which  are  found  are  as 
follows  : — (a)  Degeneration  of  hepatic  cells,  beginning  at  the 
periphery  of  the  hepatic  lobule  and  proceeding,  in  some  areas, 
to  total  cell  destruction  (Plate  III.  a).  In  the  early  stages 
the  affected  cells  become  cloudy  and  lose  their  affinity  for 
stains  ;  later  the  cell  body  becomes  disintegrated  and  breaks 
down  into  debris,  the  nucleus  being  the  last  part  to  persist. 
(b)  Interstitial  haemorrhages,  either  diffused  and  slight  in 
extent,  or  forming  gross  haemorrhages,  with  compression  or 
disintegration  of  the  liver  substance.  Considerable  deposits 
of  fibrin  are  also  found,  (c)  Thrombosis  of  vessels,  for  the 
most  part  those  of  microscopic  size,  sometimes  affecting 
large  ones.  Two  kinds  of  thrombi  have  been  observed, 
viz.,  the  common  fibrinous  thrombus,  and  the  non-fibrinous 
or  agglutinative  thrombus.  The  presence  of  the  latter  was 
observed  by  Flexner  and  others  ;  their  importance  from  the 
standpoint  of  causation  will  be  referred  to  below,  (d)  De- 
generative changes  have  been  found  in  the  endothelial 
lining  of  the  capillaries,  and  to  these  changes  the  interstitial 
haemorrhages  are  probably  due. 

The  changes  just  described  usually  occur  diffused  over 
the  whole  organ  in  greater  or  less  degree.  In  addition  blocks 
of  tissue  of  considerable  size  may  be  affected,  the  so-called 
'  massive  necrosis.'  This  probably  arises  from  blocking  of 
a  vessel  of  considerable  size  by  thrombosis,  which  suddenly 
cuts  off  the  blood  supply  from  the  area  served  by  it. 

Fatal  cases  of  eclampsia  occasionally  occur  in  which 
little  if  any  morbid  changes  can  be  found  in  the  liver. 

Spleen. — The  spleen  is  enlarged,  congested,  and  fre- 
quently presents  haemorrhages,  situated  sometimes  beneath 
the  capsule,  sometimes  in  the  connective-tissue  trabeculae  of 
the  organ.  Degenerative  changes  are  not  marked,  as  the 
spleen  contains  no  epithelium,  but  areas  of  necrosis  may  be 
found. 

Brain. — Morbid  appearances  are  found  in  90  per  cent,  of 
cases  ;  they  consist  of  small  haemorrhages  and  scattered 
areas  of  necrosis  ;  in  the  neighbourhood  of  the  areas  of 
necrosis  capillary  thrombosis  similar  to  that  in  the  liver  is 
found.     Occasionally  a  large  cortical  or  ventricular  haemor- 


120  ABNORMAL  PREGNANCY 

rhage  is  found  ;  five  cases  of  this  kind  have  been  collected  by 
Fairbain  and  Carver. 

Heart. — Scattered  areas  of  cloudy  degeneration  and 
necrosis  a-lso  occur  in  the  heart  muscle. 

Among  the  rarer  changes  found  in  eclampsia  may  be 
mentioned  necrosis  in  the  pancreas  and  certain  of  the 
endocrinous  glands,  and  embohc  infarction  of  the  lungs ; 
the  infarcts  may  contain  vilh,  syncytial  masses,  and  masses 
of  necrotic  tissue  from  the  hver.  As  illustrating  the 
general  tendency  to  haemorrhage  in  eclampsia  it  may  be 
mentioned  that  gross  haemorrhages  are  sometimes  found 
apart  from  the  viscera,  e.g.  in  the  connective  tissue  of  the 
abdomen. 

Foetus. — It  is  a  significant  fact  that  convulsions  may 
occur  in  the  child  born  of  an  eclamptic  mother  ;  usualty, 
however,  it  is  born  dead.  In  the  liver,  changes  resembling 
those  in  the  maternal  liver  have  been  met  with,  and  some 
observers  state  that  they  can  always  be  fomid.  Renal 
changes  also  occur,  but  it  is  difficult  to  distinguish  them  from 
similar  changes,  not  uncommonly  fomid,  in  foetuses  which 
die  from  other  causes. 

Etiology. — {a)  Of  the  Albuminuria  of  Pregnancy .- — ^The 
changes  met  mth  can  all  be  best  explained  on  the  assump- 
tion that  a  toxaemic  condition  precedes  them.  The  immediate 
cause  of  the  appearance  of  albumen  in  the  urine  is  to  be 
found  in  the  degenerative  changes  in  the  renal  cortex. 
Anaemia  of  the  cortex  from  arterial  spasm,  directly  set  up  by 
a  toxic  condition  of  the  blood  circulating  through  the  kid- 
neys, is  probably  the  first  change.  The  degenerative 
changes  in  the  renal  epithehum  which  follow,  lead  to  albu- 
minuria and  the  formation  of  casts,  and  thus  the  morbid 
condition  of  the  maternal  blood  becomes  aggravated  by  the 
deficient  functional  activity  induced  in  the  kidnej^s.  Dila- 
tation of  the  ureters,  when  present,  may  be  a  contributory 
factor  in  their  causation,  but  the  state  of  the  blood  is 
probably  the  essential  factor  in  all  cases.  General  anaemia 
and  anasarca  may  also  be  explained  by  the  toxic  con- 
dition of  the  blood  ;  and  the  same  explanation  wiU 
obviously  account  for  the  death  of  the  foetus  in  utero, 
through  direct  intoxication  or  through  the  changes  induced  in 
the  placenta.    When  eclampsia  supervenes,  during  the  course 


ECLAMPSIA  121 

of  albuminuria,  it  is  probable  that  the  morbid  condition  of  the 
blood  steadily  increases,  gradually  inducing  changes  in  the 
liver,  and  when  the  toxaemia  reaches  a  certain  height  convul- 
sions suddenly  come  on.  In  this  way  the  clinical  phenomena 
of  albuminuria  and  of  eclampsia  may  be  alike  referred  to  a 
toxic  condition  of  the  blood,  which  may  yield  to  appropriate 
treatment,  or  which  may  progressively  increase  until  it 
attains  a  degree  of  severity  incompatible  with  life. 

(6)  Of  Eclampsia. — Although  albuminuria  and  eclampsia 
are  so  closely  related  in  sequence  to  one  another  they 
are  not  absolutely  interdependent.  Instances  of  eclampsia 
occur  in  which  there  was  no  recognisable  preliminary  stage 
of  albuminuria  ;  the  disease  supervenes  without  serious 
warning  in  a  pregnant  woman  apparently  in  good  health. 
In  these  cases  eclampsia  and  albuminuria  appear  simul- 
taneously. In  other  and  rarer  instances  eclampsia  may  run 
its  course  to  a  fatal  ending  without  albumen  being  found  in 
the  urine  at  all,  and  without  the  characteristic  renal  changes 
being  developed.  The  hepatic  changes  are  however,  well 
marked  in  such  cases,  and  in  them  the  stress  of  the  poisoning 
appears  to  fall  upon  the  liver.  It  is,  therefore,  probable 
that  the  toxic  bodies  concerned  are  complex  ;  that  some 
act  especially  on  the  kidneys,  others  on  the  liver,  and  that 
they  are  present  in  variable  proportions.  It  may  in  time 
prove  possible  to  distinguish  two  corresponding  clinical  types 
of  eclampsia,  the  renal  and  the  hepatic  ;  in  the  meantime, 
however,  our  knowledge  of  the  correlation  of  clinical  types 
with  post-mortem  changes  is  not  sufficient  to  warrant  this. 

At  the  present  time  we  cannot  go  further  than  to  say 
that  eclampsia  is  due  to  a  complex  toxaemia,  the  constituent 
factors  of  which  are  still  to  be  worked  out. 

An  interesting  analogy  has  been  pointed  out  by  Leith 
Murray,  between  the  pathological  changes  found  in  eclampsia 
and  those  due  to  death  from  snake  poisoning.  Cobra  venom 
contains  five  toxic  principles,  which  can  be  traced  by  the 
effects  which  they  produce,  viz.,  (1)  thrombotic  ;  (2)  hsemo- 
lytic  ;  (3)  hsemagglutinative  ;  (4)  endotheliolytic  ;  (5)  neuro- 
toxic. Leith  Murray  suggests  that  similar  effects  can  all  be 
traced  in  cases  of  eclampsia  ;  (1)  fibrinous  thrombosis  is 
widespread  in  the  liver  ;  (2)  destruction  of  blood  cells  occurs  ; 
(3)  non-fibrinous  thrombi  are  found  ;    (4)  degeneration  of 


122  ABNORMAL   PREGNANCY 

capillary  endotheKum  is  common  ;  (5)  convulsions  and 
coma  may  be  due  to  direct  action  of  a  toxic  body  upon  the 
higher  nerve  centres. 

This  analogy  cannot  fail  to  lend  support  to  the  toxsemic 
theory  of  the  causation  of  this  disease. 

Reasons  have  been  advanced  on  a  previous  page  for 
believing  that  the  chorion  is  the  ultimate  source  of  all 
pregnancy  toxaemias.  Eclampsia  is  a  disease  which  is 
unlino^^^l  before  the  formation  of  the  placenta,  with  the 
exception  that  a  few  cases  have  been  recorded  in  connection 
with  vesicular  mole.  Fully  developed  chorionic  villi  are 
accordingly  the  source  to  which  we  must  look  for  the  toxins 
of  eclampsia.  Up  to  the  present  time  attempts  to  isolate  from 
the  placenta  of  eclampsia  toxic  bodies  capable  of  reproducing 
the  symptoms  in  animals  have  not  been  convincing,  o^^ing 
to  the  great  technical  difficulties  involved  in  the  preparation 
of  the  material.  Until  this  has  been  done,  actual  proof  of 
the  placental  source  of  the  toxins  is  lacking.  This  cannot 
be  held  however,  to  discredit  the  theory,  which  is  supported 
by  much  indirect  e^^dence  and  which  reasonably  explains 
the  main  features  of  the  disease. 

One  serious  objection  to  the  theory  of  placental  toxsemia 
must,  however,  be  mentioned,  viz.,  that  in  a  considerable 
proportion  of  cases  eclampsia  begins  after  labour,  during 
the  first  few  days — first  to  fourth — of  the  puerperium  (see 
p.  527).  Now  chnical  observations  have  sho^Mi  that  rapid 
improvement  in  the  condition  of  the  kidneys  usually  foUows 
delivery  in  cases  of  albuminuria,  and  it  is  beheved  that  the 
toxic  condition  of  the  blood  also  speedily  diminishes.  In 
the  cases  under  consideration  we  must  assume  continuance 
or  exacerbation  of  the  toxaemia  after  labour.  This  presents 
great  difficulties,  since  it  is  the  opposite  of  what  usually 
occurs  ;  but  it  may  be  said  that  these  cases  are  almost 
equally  difficult  to  explain  upon  any  other  theory  of  eclamp- 
sia that  has  ever  been  advanced.  CHnically  they  are  often 
severe,  and  even  fatal,  and  show  the  post-mortem  characters 
already  described. 

When  it  is  recollected  that  the  toxaemia  of  eclampsia  is 
a  complex  condition,  the  difficulty  offered  by  puerperal  cases 
is  diminished.  The  widespread  degenerative  changes  which 
have  been  described  in  the  kidneys,  liver,  spleen,  endocrinous 


ECLAMPSIA  123 

glands,  pancreas,  etc.,  must  inevitably  lead  to  such  formid- 
able changes  in  metabolism  as  to  maintain  a  condition  of 
toxaemia,  even  after  the  source  of  the  toxic  bodies  which 
induced  these  changes  has  been  eliminated.  The  failure  of 
the  eliminatory  functions  further  aggravates  the  general  con- 
ditions. Clinical  evidence  clearly  shows  that  the  ahmentary 
canal  is  one  great  channel,  probably  a  vicarious  one,  for  the 
elimination  of  the  eclamptic  toxins.  Gastric  and  intestinal 
lavage  influences  favourably  the  course  of  the  disease,  and 
Tweedy  has  further  shown  that  the  withholding  of  all 
stomach  food,  except  water,  also  exerts  a  favourable  influ- 
ence. Diminution  of  the  excretion  of  urine,  and  the  appear- 
ance of  diacetic  acid  and  /3  oxy-butyric  acid  in  the  blood 
are  not  the  direct  result  of  the  toxins,  but  are  due  to  the 
structural  organic  changes  induced  by  them.  Certain  of 
the  symptoms  of  eclampsia,  such  as  high  blood  pressure, 
may  be  due  to  excitation  of  the  adrenals  or  pituitary, 
others  such  as  the  rapid  pulse,  may  be  due  to  excitation  of 
the  thyroid  or  parathyroids. 

It  is,  therefore,  obvious  that  when  the  eclamptic  toxins 
have  begun  their  work  their  effects  will  soon  be  supple- 
mented by  other  toxins  derived  from  perverted  action  of 
viscera  of  great  importance,  or  from  extensive  areas  of  tissue 
which  have  undergone  necrosis.  The  widespread  changes 
thus  induced  may  lead  to  acute  toxaemia,  even  after  the 
absorption  of  further  quantities  of  the  primary  poison  has 
been  rendered  impossible  by  the  removal  of  the  placenta. 

If  it  is  admitted  that  the  weight  of  evidence  is  in  favour 
of  the  placenta  as  the  source  of  the  eclamptic  toxins,  we 
still  do  not  know  how  their  production  is  brought  about. 
The  suggestion  of  Young  has  been  already  mentioned, 
viz.,  that  they  are  the  products  of  autolysis  resulting 
from  massive  necrosis  induced  by  sudden  arrest  of  the 
maternal  blood  supply  to  a  large  area  of  placental  tissue. 
This  again  may  be  associated  with  retro -placental  haemor- 
rhage causing  separation  from  the  uterine  wall,  or  extensive 
thrombosis  of  the  sub-placental  sinuses.  On  the  other 
hand,  the  toxaemia  may  conceivably  be  induced  by  the 
passage  of  syncytial  masses  in  abnormal  quantity  into  the 
maternal  blood.  In  what  manner  this  could  be  brought 
about  we  do  not  know. 


124  ABNORMAL   PREGNANCY 

Only  brief  mention  can  be  made  of  the  older  theories  of 
the  causation  of  eclampsia  which  have  been  advanced. 

The  UrcEmic  Theory. — This  was  one  of  the  earliest 
scientific  attempts  to  explain  eclampsia.  In  its  clinical 
features  eclampsia  closely  resembles  uraemia  ;  but  chronic 
renal  disease  which  is  the  usual  precursor  of  uraemia,  is 
quite  uncommon  in  cases  of  eclampsia,  and  the  post-mortem 
changes  are  quite  different. 

The  Pressure  Theories. — The  occasional  occurrence  of 
dilatation  of  the  ureter  in  eclampsia  has  been  already  referred 
to.  When  this  association  was  first  observed,  it  was  regarded 
as  a  possible  explanation  of  the  disease,  the  convulsions  being 
regarded  as  induced  by  acute  dilatation  of  the  ureter  and  renal 
pelvis.  This  theory  is  disproved  by  the  fact  that  ureteral 
pressure  is  only  an  occasional  accompaniment  of  the  disease. 
The  right  ureter  is  the  one  usually  affected,  and  direct  com- 
pression of  this  duct  against  the  pelvic  brim  by  the  gra^dd 
uterus  or  by  the  foetal  head,  is  the  probable  explanation  of  it. 

Compression  of  the  renal  veins  by  the  uterus  in  the  last 
two  months  of  pregnancy  has  also  been  suggested  as  a  cause, 
but  there  is  no  evidence  whatever  in  favour  of  it. 

Bacterial  infection  has  also  been  suggested,  but  no 
isolation  of  an  organism  has  ever  been  made.  In  this  con- 
nection, however,  it  may  be  noted  that  there  is  a  certain 
amount  of  evidence  that  eclampsia  may  assume  an  epidemic 
form  ;  certainly  its  occurrence  in  a  series  of  cases,  followed 
by  long  intervals  of  freedom,  has  been  observed  in  several 
maternity  hospitals. 

Treatment  of  the  Albuminuria  of  Pregnancy. — The  early 
recognition  of  the  occurrence  of  albuminuria  in  pregnancy 
is  of  great  importance  both  to  the  mother  and  the  foetus. 
Regular  examination  of  the  urine  every  month  during  the 
latter  half  of  pregnancy  in  the  case  of  a  primigravida, 
whether  healthy  or  not,  ought  to  be  regarded  as  indispensable 
in  order  to  obtain  the  earhest  indication  of  renal  trouble. 
The  presence  of  albumen  is  a  warning  sign  that  a  state  of 
toxcemia  may  be  present.  Further  investigation  must  then 
be  made  in  order  to  decide  whether  the  condition  is  a  toxic 
albuminuria  or  not.  The  importance  of  treating  albumin- 
uria early  lies  in  the  fact  that  such  treatment  is  almost 
always   successful    in    averting    eclampsia,    and    must    be 


ECLAMPSIA  125 

insisted  upon  in  all  cases,  whether  the  patient  is  obviously 
ill  or  not.  During  the  course  of  the  treatment  daily  estima- 
tions of  the  total  urinary  secretion  and  of  the  output  of  urea 
ought  also  to  be  made,  for  a  fall  in  the  excretion  of  urea  is 
an  important  premonitory  sign  of  eclampsia. 

The  treatment  consists  in  the  main  in  promoting  free 
action  of  the  various  organs  of  excretion,  and  regulating  diet 
so  as  to  diminish  as  far  as  possible  the  work  thrown  upon  the 
digestive  organs,  especially  the  hver.  Milk  should  be  the 
staple  article  of  diet,  and  the  patient  should  take  from  3  to  4 
pints  daily,  but  except  in  the  worst  cases  fish  and  chicken 
may  be  added.  The  diet  should  be  free  from  salt.  Alcohol, 
meat,  and  rich  food  must,  of  course,  be  forbidden,  and  the 
skin  should  be  kept  acting  freely  by  daily  sponging.  In  a 
severe  case  the  patient  should  be  confined  to  bed,  and  the 
eliminative  treatment  described  on  p.  533  carried  out  either 
partially  or,  if  necessary,  in  its  entirety.  The  effect  of 
treatment  can  easily  be  watched  by  systematic  examination 
of  the  urine,  and  in  a  favourable  case  the  amount  of  albumen 
will  diminish  and  the  casts  disappear,  while  the  amount  of 
urea  remains  satisfactory  ;  but  it  will  be  remembered  that 
upon  milk  diet  the  excretion  of  urea  is  naturally  below 
normal.  The  anasarca  wiU  usually  diminish  greatly  if  the 
patient  is  kept  in  bed.  Sometimes  a  large  labial  swelling 
due  to  oedema  is  formed,  which  causes  considerable  distress  ; 
this  may  be  reheved  by  puncture  with  a  Southey's  tube 
under  careful  antiseptic  precautions.  If  the  course  of  the 
disease  cannot  be  controlled  in  this  way  the  prognosis  is 
grave  ;  the  foetus  will  probably  die  in  utero  ;  or  premature 
labour  may  come  on,  with  the  sacrifice  of  the  life  of  the 
child  ;  or  possibly  the  dreaded  complication  of  eclampsia 
may  supervene. 

In  all  serious  cases  an  ophthalmoscopic  examination  of  the 
fundus  should  be  made.  If  retinal  haemorrhage  or  exudates 
are  found  the  condition  is  too  grave  for  palliative  treatment 
and  pregnancy  must  be  terminated.  A  high  percentage  of 
albumen,  persisting  in  spite  of  treatment,  is  of  almost  equally 
grave  significance. 

The  induction  of  premature  labour  in  cases  which  resist 
medical  treatment  is  perfectly  justifiable  and  should  not  be 
delayed.     It  offers  an  escape  from  the  risks  of  eclampsia, 


126  ABNORMAL  PREGNANCY 

and,  the  chances  of  the  foetus  being  already  seriously 
jeopardised,  the  question  can  be  weighed  almost  solely  with 
reference  to  the  interests  of  the  mother.  The  treatment  of 
eclampsia  will  be  considered  in  connection  with  the  com- 
plications of  labour  (p.  530). 

Hyperemesis  Gravidarum  :    Toxaemic  Vomiting 

The  common  occurrence  of  nausea  and  vomiting  as  a 
symptom  of  normal  pregnancy,  present  usually  from  the 
second  to  the  fourth  or  fifth  month,  has  been  mentioned  on 
a  previous  page  (p.  85).  As  a  symptom  it  varies  greatly  in 
severity,  but  does  not  affect  the  patient's  health  and  has  no 
unfavourable  influence  upon  the  ovum.  The  disease  known 
as  hyperemesis  gravidarum  is  met  mth  at  the  same  period 
of  gestation  and  all  gradations  between  ordinary  morning 
sickness  and  the  worst  form  of  this  disease  may  be  met  vrith. 
Great  divergence  of  opinion  has  been  expressed  upon  its 
causation,  and  it  has  gradually  become  evident  that  a  number 
of  different  conditions  have  been  included  and  described 
under  the  same  name.  Three  groups  of  cases,  the  causation 
of  which  is  essentially  different,  may  be  distinguished,  viz., 
associated  vomiting,  hysterical  vomiting,  and  toxcemic 
vomiting. 

Associated  Vomiting. — Such  conditions  as  gastric  ulcer, 
gastric  cancer,  alcoholic  gastritis,  cirrhosis  of  the  hver,  and 
cerebral  disease — conditions  which  are  all  characterised  by 
vomiting — when  occurring  in  association  with  pregnancy, 
may  give  rise  to  intractable  vomiting.  These  cases  must 
therefore  be  excluded  by  careful  clinical  examination  before 
the  case  can  be  considered  as  an  example  of  vomiting  due  to 
pregnancy.  Occasionally  chronic  intestinal  obstruction  in 
pregnancy  has  been  overlooked  on  account  of  the  obtrusive 
character  of  the  vomiting,  and  the  case  treated  as  one  of 
toxaemic  vomiting,  with  disastrous  results. 

Hysterical  Vomiting. — Severe  and  persistent  nausea  and 
retching  are  not  infrequently  met  with  in  pregnant  women  of 
neurotic  temperament  ;  no  loss  of  flesh  or  other  sign  of 
illness  accompanies  it,  and  although  troublesome  the  con- 
dition is  of  small  clinical  importance.  But  sometimes  very 
severe  vomiting  from  hysteria  occurs  in  pregnancy.     As  a 


TOXEMIC   VOMITING  127 

rule,  hysterical  vomiting  does  not  lead  to  loss  of  flesh,  but 
wasting  is  often  associated  with  severe  forms  of  neurasthenia; 
and  in  pregnant  women  an  alarming  combination  of  the  two 
symptoms  of  vomiting  and  loss  of  flesh  is  sometimes  met  with 
from  hysteria.  The  urine,  although  diminished  in  quantity, 
from  vomiting  or  from  diminished  intake  of  fluid,  remains 
otherwise  healthy.  This  point  is  of  great  importance  in 
diagnosis.  Other  manifestations  of  hysteria  are  often  present 
in  such  cases,  and  even  in  their  absence  the  true  nature  of  the 
case  may  be  demonstrated  by  its  being  curable  by  strong 
mental  impressions,  by  hypnotic  suggestion,  or  by  isolation. 
It  is  well  known  that  in  women  of  neurotic  temperament  the 
tendency  to  hysterical  manifestations  is  greatly  aggravated 
by  pregnancy.  Numerous  cases  have  been  recorded  in  which 
hyperemesis  gravidarum  has  been  cured  by  the  treatment  of 
such  local  conditions  as  backward  displacement  of  the  gravid 
uterus,  laceration  and  erosion  of  the  cervix,  &c.  Now  these 
local  conditions  cannot  be  accepted  as  the  cause  of  hyper- 
emesis, for  they  frequently  occur  in  pregnant  women  without 
leading  to  this  symptom,  and  hyperemesis  frequently  occurs 
when  they  are  absent.  To  say  that  the  vomiting  is  '  reflexly  ' 
excited  by  such  pelvic  lesions  is  an  assumption  for  which  no 
warrant  exists.  The  cures  recorded  in  such  circumstances 
can  only  be  attributed  to  '  suggestion  ' — i.e.,  the  mental  effect 
produced  upon  a  neurotic  patient  by  the  treatment  adopted. 
Toxsemic  Vomiting. — To  this  class  only  a  small  propor- 
tion of  the  cases  of  excessive  vomiting  belong  ;  although  this 
class  is  small  it  is,  however,  very  important  for  the  cases  are 
all  severe  and  intractable,  and  a  considerable  percentage 
ends  fatally.  There  are  definite  reasons  for  regarding  these 
cases  as  toxsemic  which  may  be  stated  as  follows  : — 

( 1 )  In  fatal  cases  changes  occur  in  the  liver  and  kidneys 
of  the  same  nature  as  those  found  in  eclampsia  (Plate  III.  6). 

(2)  The  ammonia  co-efficient  is  increased. 

(3)  In  the  later  stages  there  may  be  partial  anuria,  the 
urine  containing  albumen  blood,  casts,  acetone  and  diacetic 
acid,  i.e.,  a  condition  of  acidosis  is  present. 

(4)  Pyrexia,  rapid  pulse  and  convulsions  are  often  present, 
as  in  eclampsia. 

(5)  The  condition  is  curable  by  terminating  pregnancyj 
except  in  the  most  advanced  stages. 


128  ABNORMAL   PREGNANCY 

It  is  improbable  that  the  toxaemia  is  of  the  same  nature 
as  that  of  eclampsia,  although  there  are  many  points  of 
resemblance  between  them.  Toxsemic  vomiting  occurs  in 
the  early  months  of  pregnancy,  while  eclampsia  is  never  met 
with  before  the  fifth  month.  The  chnical  feature  which 
characterises  the  one  is  vomiting,  the  other  convulsions. 
Signs  of  renal  involvement  occur  early  in  the  one,  late  in  the 
other.  And  again,  according  to  most  observers  the  hepatic 
changes,  although  consisting  in  both  cases  mainly  of  haemor- 
rhage and  necrosis,  commence  in  the  centre  of  the  hepatic 
lobule  in  pernicious  vomiting,  in  the  periphery  of  the  lobule 
in  eclampsia.  The  points  of  resemblance  justify  the  view 
that  both  are  chorionic  toxaemias ;  the  points  of  difference  may 
be  due  to  the  fact  that  pernicious  vomiting  occurs  before  and 
eclampsia  after  the  full  development  of  the  placenta.  The 
placental  chorion  may  perhaps  produce  toxins  of  a  somewhat 
different  kind  from  those  produced  by  the  early  chorionic 
membrane. 

Clinical  Features  of  Toxcemic  Vomiting. — In  the  early 
stages  of  the  disease  there  is  little  or  nothing  to  indicate  the 
serious  nature  of  the  condition.  The  normal  morning  sick- 
ness of  pregnancy  may  be  unusually  severe,  and  instead  of 
abating  it  becomes  more  and  more  persistent.  It  is,  as  a 
rule,  not  untU  severe  vomiting  has  been  in  progress  for  some 
time  that  any  definite  ill-effects  appear.  Then  vomiting 
begins  to  occur  independently  of  food  being  taken  into  the 
stomach,  and  in  addition  everything  swallowed  is  rejected, 
but  the  vomit  consists  only  of  food  and  bile-stauied  fluid. 
The  tongue  remains  clean,  and  the  general  condition  is  good. 
The  next  changes  to  appear  are  loss  of  weight  and  quickening 
of  the  pulse  rate  ;  the  latter  forms  one  of  the  most  useful 
indices  of  the  severity  of  the  case,  and  a  pulse  rate  persistently 
over  100  is  always  to  be  regarded  as  of  grave  significance. 
The  tongue  now  becomes  furred,  and  sometimes  diarrhoea 
appears  ;  sleeplessness  and  muscular  twitchings  are  also 
sometimes  met  with.  Severe  epigastric  pain  is  often  com- 
plained of  and  the  vomited  matters  may  contain  blood. 
Abortion  may  occur  spontaneously,  and  rapid  disappearance 
of  the  symptoms  foUows  the  evacuation  of  the  uterus  in 
the  earlier  stages  of  the  disease. 

If  pregnancy  continues  the  disease  passes  into  its  final 


TOXEMIC   VOMITING  129 

phase,  characterised  by  a  degree  of  anuria,  the  scanty  urine 
containing  albumen,  and  the  other  bodies  just  mentioned ; 
sHght  icterus  is  often  met  with  ;  the  temperature  often  rises 
to  100°  or  over,  although  almost  as  frequently  it  will  be 
subnormal ;  the  pulse  rate  rises  to  120  or  higher,  and  a  train 
of  nervous  symptoms  develops  which  are  of  the  gravest 
prognostic  significance,  viz.  restlessness,  loss  of  memory,  low 
delirium,  and  convulsions  or  coma.  If  at  this  stage  abortion 
should  occur  little  or  no  benefit  ensues  from  the  evacuation 
of  the  uterus,  and  a  fatal  result  is  almost  inevitable.  The 
mortality  of  toxsemic  vomiting  is  probably  50  to  60  per  cent. 

Diagnosis. — Cases  of  associated  vomiting  can  be  recog- 
nised only  by  careful  clinical  examination,  and  by  bearing 
in  mind  the  possibility  of  such  a  cause  in  every  case  of 
vomiting  of  pregnancy.  Cases  of  the  hysterical  type  are 
very  difficult  to  distinguish  from  toxsemic  cases  in  the  initial 
stages  ;  in  both  the  only  symptom  may  be  intractable 
vomiting  with  a  clean  tongue  and  a  normal  pulse  rate  ;  but 
as  a  rule  the  hysterical  cases  are  characterised  more  by 
nausea  and  severe  retching  than  by  the  ejection  of  the  actual 
stomach  contents.  Nevertheless  cases  of  hysterical  vomit- 
ing may  occur  in  which  wasting  comes  on  from  actual 
starvation.  In  such  cases  other  signs  of  the  neurotic 
temperament  must  be  sought  for,  and  in  some  cases  the 
common  '  stigmata  '  of  hysteria,  such  as  anaesthesia  of  the 
fauces,  and  points  of  spinal  tenderness,  may  be  found.  The 
urine  is  normal,  except  that  the  ammonia  nitrogen  may  be 
abnormally  high.  The  favourable  effect  of  isolation  and 
trained  nursing  often  confirms  the  diagnosis. 

The  points  specially  to  be  relied  upon  as  indications  of 
toxcemic  vomiting  are  (1)  the  presence  of  acetone  and  diacetic 
acid,  albumen  and  blood  in  the  urine  ;  (2)  a  persistently  rapid 
pulse  rate  ;  (3)  marked  loss  of  flesh  ;  (4)  furring  of  the 
tongue,  signs  of  jaundice,  and  delirium.  When  in  doubt,  it 
is  better  to  regard  the  case  as  one  of  toxsemic  vomiting  and 
treat  it  as  such.  It  will  be  noticed  that  in  the  later  stages 
certain  points  of  resemblance  to  eclampsia  are  met  with  in 
the  condition  of  the  urine  and  the  appearance  of  coma  and 
convulsions.  These  points  must  be  considered  in  relation 
to  the  post-mortem  appearances,  which  closely  resemble 
those  of  eclampsia, 

E.M,  9 


130  ABNORMAL   PREGNANCY 

Treatment. — Before  treatment  is  begun  the  greatest  care 
should  be  exercised  in  excluding  any  organic  disease  to  which 
the  vomiting  may  be  due,  and  in  establishing  the  diagnosis 
of  pregnancy.  Time  may  be  required  to  distinguish^the 
hysterical  type  from  the  true  toxsemic  vomiting  ;  when  the 
hysterical  factor  is  obvious  the  patient  should  be  isolated 
from  her  friends  and  placed  in  charge  of  an  experienced 
nurse.  Cases  of  moderate  severity  should  at  first  be  treated 
by  confinement  to  bed  and  careful  feeding  ;  small  quantities 
— 2  to  3  ounces — of  milk  or  some  peptonised  food  being  given 
every  two  hours.  If  this  is  not  retained,  albumen  water 
alone  should  be  given  for  twenty-four  hours,  in  small 
quantities  at  regular  intervals,  and  rectal  alimentation 
employed  in  addition.  It  may  be  necessary  to  stop  aU  fluids 
by  the  mouth  and  use  rectal  ahmentation  alone  for  four  or 
five  days.  Drugs  are  of  little  benefit,  but  the  following  may 
be  given  a  trial  :  1 -minim  doses  of  tincture  of  iodine  well 
diluted  every  hour,  bismuth  with  hydrocyanic  acid,  cocaine, 
and  oxalate  of  cerium.  In  hysterical  cases  a  quarter  of  a 
grain  of  morphia  may  be  given  hypodermically,  followed  a 
quarter  of  an  hour  later  by  a  quantity  of  fluid  food,  such  as 
egg  and  milk.  The  food  will  probably  be  retained  and 
digested  during  the  sleep  which  follows.  Occasionally  a 
hysterical  case  can  be  completely  arrested  in  this  way. 
Washing  out  the  stomach  will  sometimes  cure  this  form  of 
vomiting  also.  Sinapisms  applied  to  the  epigastrium,  and 
ice-bags  to  the  spine,  have  been  found  useful. 

Toxcemic  cases,  or  cases  assumed  to  be  such,  should  in 
addition  be  treated  by  the  '  eliminative  method  '  described 
on  p.  533.  Venesection  is  usually  unsuitable  on  account  of 
the  exhaustion  produced  by  prolonged  starvation,  but  the 
other  methods  are  all  useful  when  applied  with  care. 
When  marked  signs  of  acidosis  are  present,  the  indication 
is  to  administer  large  doses  of  an  alkaline  salt,  together 
with  a  readily  assimilable  carbohydrate  substance,  such  as 
glucose.  Bicarbonate  of  soda  should  be  given  in  sixty-grain 
doses,  per  rectum  if  necessary,  and  repeated  every  four  hours 
until  the  reaction  of  the  urine  becomes  deflnitely  alkaline. 
Glucose  can  be  administered  in  the  same  manner  in  doses  up 
to  10  ounces  of  a  6  per  cent,  solution. 

The   obstetric   treatment    consists    in    the    induction    of 


TOXEMIC   VOMITING  131 

abortion.  The  evacuation  of  the  uterus  does  not  always 
arrest  the  vomiting ;  in  the  most  advanced  stages  of  the 
disease  it  has  Httle  effect.  Induction  of  abortion,  if 
undertaken  in  time,  should  prove  to  be  a  safe  and  easy 
means  of  arresting  the  disease,  but  the  statistics  of  induced 
abortion  are  extremely  unfavourable.  This  is  probably  due 
in  the  main  to  the  fact  that  the  condition  of  the  patient  has 
become  desperate  from  delay  before  induction  is  resorted  to. 
Lepage  was  able  to  report  66  per  cent,  of  recoveries  in  a 
series  of  thirty-two  recent  cases  in  which  induction  was 
practised,  but  even  this  high  mortality  compares  favourably 
with  results  published  by  previous  observers.  Induction 
should  be  advised  before  the  febrile  stage  is  reached.  If 
vomiting  persists  in  spite  of  eliminative  and  dietetic  treat- 
ment, and  is  accompanied  by  a  pulse  rate  of  100  or  over,  or 
by  marked  emaciation,  and  the  presence  of  albumen  in  the 
urine,  the  patient's  life  is  in  great  danger  ;  there  need  be 
no  hesitation  at  this  stage  in  advising  that  pregnancy  should 
be  ended,  without  waiting  for  the  appearance  of  symptoms 
of  greater  gravity. 

The  methods  by  which  abortion  may  be  induced  will  be 
considered  in  a  later  section. 


We  have  next  to  consider  certain  minor  disorders 
associated  with  pregnancy  which  may  be  included  among 
the  toxaemias,  although  their  dependence  upon  toxaemia  is, 
in  the  present  state  of  our  knowledge,  a  matter  of  assump- 
tion ;  they  may  eventually  be  shown  to  be  indications  of  some 
other  condition.  Ptyalism  or  Sialorrhoea  is  sometimes  ex- 
tremely troublesome  in  the  early  months  during  the  period  at 
which  morning  sickness  appears  ;  sometimes  it  is  associated 
with  severe  vomiting.  Usually  it  is  not  of  great  clinical  im- 
portance, but  in  rare  cases  it  is  associated  with  rapid  wasting, 
and  grave  deterioration  of  the  general  health.  Borissard 
has  recorded  a  case  in  which  the  patient  lost  13  kilos.  (28  to 
29  pounds)  in  a  week.  Pruritus  limited  to  the  external 
genital  organs  is  of  frequent  occurrence  during  pregnancy, 
and,  although  troublesome,  is  never  of  grave  importance. 
Sometimes,  however,  general  pruritus  affecting  the  skin  of 

9—2 


132  ABNORMAL   PREGNANCY 

the  entire  body  occurs  ;  it  may  be  associated  with  eruptions 
of  erythematous  or  eczematous  type,  or  the  skin  may  be 
unaffected  in  appearance.  General  pruritus  may  lead  to 
serious  consequences  from  sleeplessness  and  exhaustion  due 
to  ceaseless  irritation.  Herpes  sometimes  of  a  severe  type 
occurs  during  pregnancy,  and  has  been  named  herpes 
gestationis.  It  occurs  on  the  external  genitalia  and  the 
trunk,  and  is  very  intractable  to  treatment.  Cases  have 
been  recently  recorded  which  have  been  successfully  treated 
by  eliminative  methods  and  it  is  possible  that  the  con- 
dition is  of  toxsemic  origin.  Mental  Disturhances . — The 
liability  of  neurotic  women  to  exacerbations  of  hysteria 
during  pregnancy  has  been  already  referred  to.  Minor  dis- 
turbances, such  as  sleeplessness,  restlessness,  and  per- 
versions of  the  appetite  (longings),  may  also  be  met  with  ; 
when  insanity  occurs  it  is  usually  in  single  women,  and  is 
attributed  largely  to  mental  distress  and  apprehension. 

Backward  Displacement  of  the  Gravid  Uterus 
(Retroversion,  Retroflexion) 

In  the  majority  of  cases  this  condition  results  from  the 
occurrence  of  conception  in  a  uterus  which  is  already  retro- 
verted  or  retroflexed  ;  more  rarely  a  normally  placed  uterus 
becomes  displaced  during  the  first  or  second  month  of 
pregnancy  by  a  fall,  a  violent  muscular  effort,  or  by  over- 
distension of  the  bladder.  Unless  a  history  of  such  occur- 
rences as  these  can  be  obtained,  there  is  no  means  of  dis- 
tinguishing between  the  two  modes  of  origin.  The  dis- 
tinction between  retroversion  and  retroflexion  is  not  of 
practical  utihty,  and  no  attempt  need  be  made  to  consider 
them  separately. 

Backward  displacement  rarely  gives  rise  to  symptoms 
until  the  end  of  the  third  month  has  been  passed  (thirteenth 
week),  and  the  symptoms  which  then  appear  are  simply 
mechanical  in  their  origin.  At  this  period  the  gravid  uterus 
is  nearly  globular  in  shape,  having  a  diameter  of  from  3|  to  4 
inches  (Fig.  44) — i.e.,  it  is  nearly  as  large  as  the  pelvic  cavity 
in  the  living  subject.  It  therefore  exerts  pressure  upon  the 
pelvic  contents,  giving  rise  to  pain  and  interference  with  the 
functions  of  the  bladder  and  rectum.     The  prominent  and 


BACKWARD   DISPLACEMENT 


133 


characteristic  symptom  is  retention  of  urine,  either  absolute 
or  associated  with  continuous  dribbling.  Sometimes  the 
onset  of  this  symptom  is  sudden,  the  patient  being  com- 
pletely unable  to  pass  water  ;  usually  the  onset  is  gradual, 
frequency  of  micturition  passing  on  to  urinary  incontinence. 
The  sudden  onset  is  always  associated  with  great  pain  and 


ve-o^i 


Urethra 


Floor    of    Poixch 
of    Douglas 


Partially  dilated    cervix 

Fig.  51. — Eetrofiexed  Gravid  Uterus  (three  and  a  half  to  four  months) 
with  Distension  and  Eupture  of  the  Bladder ;  Commencement  of 
Abortion.     Prom  a  Frozen  Section.     (Schwyzer.) 


distress  ;  with  the  gradual  onset  the  patient  may  be  quite 
unconscious  of  the  over-distended  state  of  the  bladder,  which 
causes  no  pain.  There  may  also  be  rectal  tenesmus,  and 
pain  in  the  back  and  posterior  aspects  of  the  legs,  but  these 
symptoms  are  of  minor  importance. 

The  manner  in  which  retention  of  urine  is  set  up  will  be 
understood  from  Fig.  57.  The  gravid  uterus  is  shown  com- 
pletely filling  the  pelvic  brim  and  cavity,  and  causing  a 


134  ABNORMAL   PREGNANCY 

certain  amount  of  compression  of  the  urethra  against  the 
back  of  the  symphysis  pubis.  But  more  striking  than  com- 
pression is  the  great  elongation  of  the  urethra,  which  is 
ahnost  double  its  normal  length.  This  elongation  results 
from  two  factors  :  (1)  upward  displacement  of  the  cervix 
and  stretching  of  the  anterior  vaginal  wall,  the  external  os 
being  at  the  level  of  the  upper  border  of  the  symphysis  : 
(2)  upward  displacement  of  the  lower  part  of  the  anterior 
uterine  wall  to  which  the  base  of  the  bladder  is  attached. 
These  two  anatomical  changes  cause  elongation  of  the  entire 
urethra  ;  this  leads  to  narrowing  of  the  lumen,  which  in  turn 
increases  the  resistance  to  evacuation  of  the  bladder,  and  so 
induces  paralytic  over-distension.  If  the  sphincter  becomes 
relaxed,  incontinence  occurs,  with  continuous  escape  of 
urine.  In  the  figure  it  is  seen  that  abortion,  indicated  by 
dilatation  of  the  cervix,  has  commenced.  The  peritoneal 
investment  of  the  bladder  is  convoluted,  and  the  organ  is 
partly  collapsed,  rupture  having  occurred  in  the  over- 
distended  state. 

Clinical  Course  and  Results. — Backward  displacement 
giving  rise  to  no  symptoms  may  be  met  with  accidentally  in 
the  second  or  third  month  :  it  usually  becomes  spontaneously 
reduced  as  the  uterus  develops.  While  the  bladder  remains 
over-distended,  spontaneous  reposition  is  impossible.  In 
rare  instances  no  urgent  symptoms  occur  at  all  even  at  the 
critical  period — the  end  of  the  third  month— and  the  uterus 
continues  its  development  in  its  abnormal  position,  giving 
rise  to  the  condition  known  as  sacculation  of  the  uterus. 
This  has  been  known  to  persist  until  term,  and  not  to  inter- 
fere mth  normal  delivery.  More  commonly  abortion  takes 
place  if  the  displacement  remains  imcorrected. 

Serious  results  may  ensue  if  the  uterus  becomes  incar- 
cerated. The  word  '  incarceration  '  is  loosely  employed,  and 
has  no  precise  significance,  but  it  may  conveniently  be  used 
to  denote  any  serious  mechanical  obstacle  to  reposition,  such 
as  pelvic  contraction,  especially  of  the  flat  variety  (see  p.  396), 
and  pexitonitic  adhesions  involving  the  uterus,  which  may 
have  been  in  existence  at  the  time  of  conception,  or  may 
have  developed  during  the  pregnancy.  Such  cases  as  these, 
when  unrelieved,  may  become  complicated  by  (1)  rupture 
of  the  bladder  ;   (2)  cystitis  ;   (3)  gangrene  and  exfohation  of 


BACKWARD   DISPLACEMENT  135 

the  vesical  mucous  membrane  ;  (4)  uraemia  or  surgical 
kidney.  With  any  of  these  complications  prognosis  is  very 
grave. 

Diagnosis. — The  occurrence  of  marked  disturbance  of  thg 
functions  of  the  bladder  in  association  with  three  or  four 
months'  amenorrhoea  should  always  raise  the  suspicion  of 
backward  displacement  of  the  gravid  uterus,  and  it  must  be 
remembered  that  troublesome  frequency  of  micturition  with 
slight  incontinence  may  be  the  only  symptoms  to  which  the 
over-distended  bladder  gives  rise.  Sudden  inability  to  pass 
water  always  brings  the  patient  to  seek  immediate  relief  ; 
but  frequency  and  slight  incontinence,  when  unassociated 
with  pain,  are  often  disregarded  by  her,  and  sometimes  mis- 
interpreted by  her  medical  attendant.  Careful  abdominal 
and  vaginal  examination  are  required  to  determine  (1)  the 
state  of  the  bladder,  (2)  the  position  of  the  uterus. 

On  abdominal  examination  an  over-distended  bladder 
reveals  itself  as  a  soft,  non-tender,  fluctuating  swelling,  super- 
ficial in  position,  and  reaching  well  above  the  umbilicus  in 
extreme  cases.  Its  size  alone  will  serve  to  distinguish  it  from 
the  gravid  uterus  at  the  third  or  fourth  month.  Any  doubt 
will,  of  course,  be  dispelled  by  passing  the  catheter.  Until 
the  bladder  has  been  evacuated,  nothing  further  can  be 
detected  on  abdominal  examination.  Signs  of  activity  in 
the  breasts  should  be  noted  as  being  presumptive  of  preg- 
nancy. 

On  vaginal  examination  the  conditions  will  be  found 
which  are  shown  in  Fig.  57.  The  first  point  which  attracts 
attention  is  the  forward  bulging  of  the  posterior  vaginal  wall, 
due  to  depression  of  the  floor  of  the  pouch  of  Douglas,  and 
filling  up  of  the  sacral  hollow  by  the  body  of  the  uterus, 
which  is  felt  as  a  smooth,  tense,  elastic  swelling.  In  conse- 
quence the  direction  of  the  vaginal  canal  is  altered  so  that  it 
passes  from  below  upwards  and  a  little  forwards,  instead  of 
upwards  and  backwards.  The  next  point  to  be  noticed  is 
the  inaccessibility  of  the  cervix,  which  cannot  be  found  at 
the  usual  level,  but  lies  high  up  behind  the  symphysis  pubis. 
Often  the  posterior  lip  alone  can  be  reached,  and  sometimes 
the  cervix  is  entirely  inaccessible  to  touch  without  employing 
anaesthesia  for  the  examination.  The  greater  the  degree  of 
flexion  present,  the  easier  will  it  be  to  reach  the  cervix  ;  in  a 


136 


ABNORMAL   PREGNANCY 


simple  retroversion  the  external  os  may  lie  well  above  the 
level  of  the  upper  border  of  the  symphysis.  After  evacua- 
tion of  the  bladder  the  bimanual  examination  will  show  that 
the  swelhng  felt  through  the  posterior  vaginal  wall  is  the 
gravid  uterus,  and  examination  per  rectum  will  allow  of  much 
more  complete  palpation  of  the  displaced  uterus  than  the 
vaginal  examination.  Confirmatory  signs  of  pregnancy  may 
be  found  in  softening  of  the  cervix,  and  purple  discoloration 
of  the  mucous  membrane  of  the  vulva.  Finally,  an  attempt 
should  be  made  to  estimate  the  mobihty  of  the  uterus,  by 
endeavouring  to  lift  it  upwards  and  forwards  in  the  pelvic 
axis  with  the  examining  finger.  The  presence  of  pelvic 
contraction  should  not  be  overlooked  as  a  cause  of  incarcera- 
tion ;  adhesions  are  very  difficult  to  diagnose,  and  their 
presence  will  not,  as  a  rule,  be  suspected  until  it  is  found  that 
some  unexpected  obstacle  to  replacement  exists. 

Dijferential  Diagnosis. — There  are  only  two  conditions 
which  may  be  said  closely  to  resemble  retroversion  of  the 
gravid  uterus — viz.,  pelvic  hcematocele  (almost  always  due  to 
extra-uterine  gestation),  and  &  fibroid  tumour  in  the  posterior 
uterine  wall.  The  former  will  be  considered  in  a  subsequent 
section  (see  p.  193).  With  regard  to  the  latter,  the  differen- 
tial diagnosis  is  easy  if  the  fibroid  uterus  is  not  gravid,  but 
very  difficult  if  pregnancy  has  occurred  ;  in  the  latter  case 
the  physical  signs  may  so  closely  resemble  those  of  a  retro- 
verted  gravid  uterus  as  to  deceive  the  most  experienced 
chnical  observer.  The  following  symptoms  usually  afford 
valuable  aid  in  distinguishing  these  conditions,  as  may  best 
be  indicated  in  a  table  thus  : 


I.  Eetioverted  Gravid 
Uterus. 


1.  Amenorrhoea 

2.  Signs  of  pregnancy 

in  Breasts  (primi- 
gravida),  Cervix, 
and  Yulva 

3.  Eetention  of  urine 


II.  Fibroid  in  Posterior 
Wall. 


Normal  naenstruation 
or  menorrhagia 

Occasionally  secretion 
in  Breasts 

No  signs  of  pregnancy 
in  Cervix  and  Vulva 

Eetention  of  urine 


III.  Fibroid  in  Posterior 
Wall  +  Pregnancy. 


Amenorrhoea  or  slight 
irregular  haemorrliage 

Signs  of  pregnancy  in 
Breasts  (primigravida), 
Vulva,  and  Cervix 

Eetention  of  urine 


The  great  majority  of  fibroids  are  hard  and  quite  unhke 
the    gravid    uterus   in    consistence,    but    sometimes    these 


BACKWARD   DISPLACEMENT  137 

tumours  become  softened  from  oedema  or  cystic  degenera- 
tion ;  and  although  multiple  fibroids  cause  the  outline  of 
the  uterus  to  become  irregular,  a  single  interstitial  or  sub- 
mucous growth  will  cause  a  symmetrical  enlargement  not 
unlike  that  of  pregnancy.  Softening  of  the  cervix  is  often 
delayed  when  pregnancy  occurs  in  a  fibroid  uterus.  These 
facts,  together  with  the  tendency  of  fibroids  occupying  the 
posterior  uterine  wall  to  occasion  retention  of  urine,  are  the 
chief  causes  of  the  difficulties  in  diagnosis.  The  immediate 
treatment  of  I.  and  III.  being  the  same,  their  differential 
diagnosis  is  not  of  great  practical  importance. 

Other  swellings,  such  as  a  small  ovarian  cyst,  are  not 
infrequently  found  occupying  the  pouch  of  Douglas  and 
displacing  the  cervix  forwards  against  the  symphysis  pubis. 
They  seldom,  however,  cause  retention  of  urine,  for  the 
reason  that  they  do  not  occasion  that  elongation  of  the 
urethra  to  which  retention  is  largely  due  in  the  case  of  the 
retro  verted  gravid  uterus.  The  differential  diagnosis  can 
usually  be  made  by  localising  the  uterus,  which  will  be 
found  to  be  of  normal  size  and  to  lie  in  front  of  the  swelling, 
and  distinct  from  it.  None  of  the  signs  or  symptoms  of 
pregnancy  will  be  met  with. 

Treatment. — Cases  of  backward  displacement  sometimes 
come  under  observation  before  the  functions  of  the  bladder 
have  been  interfered  with  ;  sometimes  the  condition  is  dis- 
covered by  accident,  sometimes  the  patient  comes  com- 
plaining of  backache.  At  this  period  no  attempt  should  be 
made  to  replace  the  uterus  ;  the  manipulations  required  are 
painful  and  sometimes  difficult  ;  abortion  not  infrequently 
follows  them  even  when  they  are  successful  ;  and  in  addition, 
replacement  is  not  required.  The  patient  should  be  put  to 
bed  and  kept  resting  for  10  to  14  days  ;  symptoms  such  as 
backache  always  disappear,  and  in  most  cases  about  the 
end  of  the  third  month  the  uterus  will  rise  spontaneously 
out  of  the  pouch  of  Douglas  into  the  normal  position.  She 
should  be  directed  to  lie  prone  on  her  face  for  several  hours 
at  a  time,  and  if  possible,  to  sleep  in  that  position. 

After  retention  of  urine  has  occurred,  the  best  method  of 
treatment  is  rest  in  bed  with  the  regular  use  of  the  catheter 
three  times  in  24  hours  ;  in  the  majority  of  cases  spontaneous 
ascent  of  the  uterus  occurs  after  three  or  four  days  ;    in 


138  ABNORMAL   PREGNANCY 

others,  however,  some  method  of  replacement  may  be 
required,  but  resort  should  not  be  made  to  these  methods 
until  the  expectant  method  has  failed. 

MetJiods  of  Replacement. — The  two  chief  methods  made 
use  of  are  :  (1)  manipulation  aided  by  posture,  ansesthesia, 
or  prolonged  rest  ;   (2)  continuous  pressure. 

(1)  Manipulation. — The  simplest  apphcation  of  this 
method  is  to  place  the  patient  in  Sims's  position  (Fig.  159) 
and,  the  bladder  having  been  evacuated,  to  endeavour  to 
push  the  fundus  upwards  and  forwards  in  the  direction  of 
the  axis  of  the  pelvic  brim  ;  this  may  be  done  mth  two 
fingers  passed  into  the  vagina,  or  with  the  index  finger  in  the 
vagina  and  the  middle  finger  in  the  rectum,,  which  allows  of 
pressure  being  more  effectively  apphed  to  the  retroverted 
fundus.  Further  aid  may  also  be  obtained  by  seizing  the 
anterior  Hp  of  the  os  externum  with  a  volsella  and  drawing 
it  downwards  while  the  fingers  push  the  fiuidus  upwards. 
This,  however,  will  not  succeed  unless  the  patient  is  tolerant 
of  pain  and  will  avoid  straining.  When  the  fundus  has  been 
raised  above  the  pelvic  brim,  the  cervix  should  be  pushed 
back  towards  the  sacral  hollow  and  the  body  dra^mi  forwards 
towards  the  pubes  with  the  external  hand.  Precisely  the 
same  manoeuvre  may  be  attempted  \dih.  the  patient  in  the 
knee-elbow  or  the  knee-chest  (genu-pectoral)  position  (Fig. 
58),  which  brings  in  the  aid  of  gravity  to  a  greater  extent, 
the  uterus  tending  to  fall  towards  the  dependent  abdominal 
walls.  If  an  ansesthetic  is  admmistered,  so  as  to  abohsh 
completely  the  muscular  reflexes,  manipulation  mil  often 
succeed  after  being  employed  unsuccessfully  mthout  it. 
The  position  of  the  patient  is  unimportant  when  under 
ansesthesia.  Even  when  manipulation  fails  at  first,  it  may 
succeed  after  a  few  days"  rest  in  bed,  and  the  use  of  saline 
purgatives  and  hot  vaginal  douchmg. 

In  Sims's  position  the  patient  hes  on  her  left  side  with  the 
left  arm  behind  her,  and  both  knees  dra^^Ti  up  to  the  abdomen, 
the  right  higher  than  the  left.  The  knee-elbow  and  knee- 
chest  positions  will  be  more  fully  described  m  a  later  section 
(see  p.  391). 

(2)  Continuous  Pressure. — This  method  is  apphed  by 
passing  into  the  vaguia  the  hj^drostatic  dilator  known  as  the 
de  Ribes  bag  (see  p.  664),  distending  it  vrdh.  air  or  water 


BACKWARD   DISPLACEMENT 


139 


(preferably  the  former),  and  allowing  it  to  remain  for  a 
period  of  six  hours  at  a  time.  This  continuous  elastic 
pressure  from  below,  when  applied  intermittently  for  a  few 
days,  sometimes  succeeds  after  manipulation  has  failed,  but 
it  causes  considerable  pain. 

Cases  which  resist  these  methods  of  replacement  are  very 
uncommon,  and  are  due  either  to  contraction  (flattening)  of 
the  pelvic  brim  or  to  the  presence  of  adhesions.  In  the 
former  condition  spontaneous  abortion  will  in  all  probability 


Fig.  58. — Eeplacement  of  Eetroverted  Gravid  Uterus  by  Manipulation 
in  Genu-Pectoral  Position.     (Bumm.) 


occur  ;  in  the  latter  it  is  best  to  allow  the  gestation  to  con- 
tinue to  term,  when  there  is  good  hope  of  spontaneous 
delivery  taking  place. 

Anteflexion  of  the  Gravid  Uterus. — During  the  last  three 
or  four  months  of  pregnancy,  when  the  uterus  is  imperfectly 
supported  by  the  lax  abdominal  walls  so  often  found  in  a 
multipara,  the  fundus  tends  to  fall  forwards,  producing 
unusual  protrusion  of  the  abdomen.  This  may  become 
exaggerated  by  the  uterus  passing  between  the  recti  muscles, 
when  they  have  become  separated  from  one  another  by  a 


140 


ABNORMAL  PREGNANCY 


distinct  interval  ;  the  uterus  being  then  supported  only  by 
the  cutaneous  structures  of  the  abdominal  wall,  the  fundus 
may  come  to  lie  at  a  lower  level  than  the  symphysis  pubis, 
producing  the  condition  called  pendulous  belly  (Fig.  59). 
The  same  condition  may  result  from,  or  be  exaggerated  by, 
extreme  pelvic  contraction,  prevent- 
ing the  descent  of  the  foetus  into  the 
pelvic  brim  ;  or  spinal  curvature, 
displacing  the  uterus  forwards.  It 
naturally  causes  considerable  discom- 
fort when  the  patient  is  in  the  erect 
position,  and  if  uncorrected  may  lead 
to  rupture  of  the  uterus  during  labour. 
Occasionalh^  an  atypical  form  of  ante- 
flexion results  from  previous  fixation 
of  the  uterus  by  hysteropexy  or  vaginal 
fixation,  and  serious  obstruction  in  la- 
bour sometimes  results.  The  treatment 
during  pregnancy  consists  in  wearing 
a  strong  well-fitting  abdominal  belt. 

Prolapse  of  the  Gravid  Uterus. — A 
completely  prolapsed  uterus  (proci- 
dentia) very  rarely  becomes  gravid. 
If  pregnancy  should  occur,  sponta- 
neous ascent  usually  takes  place  about 
the  third  month  ;  but  the  uterus  may 
become  '  incarcerated,'  when  sponta- 
neous abortion  will  almost  inevitably 
occur.  ]\linor  degrees  of  prolapse  of 
the  uterus  are  frequently  met  with  in 
pregnancy  ;  they  only  require  treat- 
ment during  the  first  three  or  fom? 
months,  as  after  this  period  the  uterus 
has  risen  into  the  abdomen  and  is 
supported  by  the  pelvic  brim.  A  ring  pessary  of  suitable 
size  is  generally  successful. 

Hernia  of  the  Gravid  Uterus. — Very  rarely  the  uterus 
forms  part  of  the  contents  of  an  inguinal  hernia,  and  in  that 
position  it  has  been  known  to  become  gravid.  This  con- 
dition is  natiu^ally  more  likely  to  affect  a  bicomute  uterus, 
one  horn  being  dra^^ii  into  the  hernial  sac.     Sometimes  also 


Fig.  59. — Anteflexion 
of  the  Gravid  Uterus  : 
Pendulous  Belly. 
(Eibemoiit-Dessaignes 
and  Lepage.) 


DOUBLE   UTERUS 


141 


/r 


the  gravid  uterus  may  enter  the  sac  of  an  umbilical  or  a 
ventral  hernia  ;  but  this  is  rare,  as  the  uterus,  by  the  time 
it  reaches  the  level  of  the  hernial  aperture,  is  usually  too  large 
to  enter  the  sac. 

Malformation  of  the  Uterus  and  Pregnancy. — Few  mal- 
formations of  the  uterus  possess  any  obstetrical  significance. 

Double  Uterus  (Uterus  didelphys  ;  Uterus  bicornis). — 
When  pregnancy  occurs  in  one  half  of  a  double  uterus,  the 


Ojuiti 


\i  '^  1-- 


Sperua. 


Fig.  60. — Pregnancy  in  a  Eadimentary  Left  Uterine  Horn.     (Kelly.) 

To  the  rigVit  is  the  well-developed  utenis.  Attached  to  the  cornu  is  the  right  tube,  which  is 
normal.  The  right  ovary  is  of  the  usual  size,  and  at  its  inner  and  lower  portion  is  a  corpus 
luteum.  Springing  from  the  left  side  of  the  utenis  at  the  level  of  the  internal  os  is  a 
muscular  band  ;  on  tracing  this  to  the  left  it  merges  into  the  rudimentary  uterine  horn. 
On  the  posterior  surface  of  this  horn  is  a  long  slit  representing  the  point  of  rupture.  The 
left  tube  passes  off  from  the  gravid  portion  of  the  rudimentary  horn.  The  arrows  indicate 
the  course  of  the  spermatozoa  and  ovum  from  the  cervix  and  right  ovary  (respectively)  to 
the  rudimentary  left  horn.     This  is  an  instance  of  '  external  wandering.' 


non-gravid  half  undergoes  marked  softening  and  enlargement, 
while  a  complete  decidual  membrance  is  formed  within  it. 
The  course  of  pregnancy  and  labour  may  be  unaffected,  and 
although  the  portio  vaginalis  and  vagina  may  be  duplicated, 
the  condition  often  passes  unrecognised.  In  binovular  twin 
pregnancy  an  ovum  may  be  lodged  in  each  half.  Occasionally 
in  a  uterus  bicornis  the  non-pregnant  horn  becomes  displaced, 
and  forms  an  obstruction  to  delivery. 


142  ABNORMAL   PREGNANCY 

Biccyrnute  Uterus  with  Rudimentary  Horn. — Sometimes  a 
bicornute  uterus  possesses  only  one  fully  developed  horn, 
the  other  being  rudimentary  ;  as  a  rule  the  lumen  of  the 
rudimentary  horn  has  no  connection  with  the  fully  developed 
one  (Fig.  60).  Pregnancy  may  occur  in  the  rudimentary 
horn  by  external  wandering  of  the  spermatozoa  ;  the 
fertihsed  ovum  may  come  from  the  ovary  of  the  same  side 
as  the  rudimentary  horn,  or  from  the  opposite  one  ;  in  the 
latter  case  it  must  cross  the  pelvic  cavity  to  enter  the 
abdominal  ostium  of  the  rudimentary  horn  (external 
wandering  of  the  ovum).  Pregnancy  in  this  position  usually 
ends  in  rupture  of  the  gravid  horn,  and  is  mistaken  clinically 
for  tubal  gestation. 

Pressure  Symptoms 

In  the  lower  extremities  and  upon  the  lower  part  of  the 
abdominal  wall,  anasarca  usualh^  appears  to  a  shght  extent 
during  the  last  two  months  of  a  first  pregnancy,  and  some- 
times in  later  pregnancies  also.  It  is  due  mainly  to  impeded 
venous  retmii  from  these  parts,  the  obstacle  being  the  com- 
pression exerted  hj  the  gravid  uterus  upon  the  iliac  veins 
at  the  pelvic  brim.  The  labia  majora  may  also  become 
oedematous,  and  form  swelhngs  of  considerable  size  even 
when  there  is  no  albuminuria.  Occasionally  only  one  labium 
or  one  leg  is  affected  with  anasarca.  Varicose  veins  often 
appear  in  the  lower  extremities,  and  vagina  or  vulva  during 
pregnancy,  being  caused  in  the  same  way  as  anasarca. 
Spontaneous  rupture  of  a  varicose  vein  during  pregnancy 
sometimes  occm-s  and  leads  to  severe  or  sometimes  to  fatal 
bleeding.  When  the  ruptured  vein  is  in  the  vaginal  wall  the 
case  is  very  likely  to  be  mistaken  in  the  first  place  for  one  of 
ante-partum  hsemorrhage,  and  only  a  careful  search  with 
the  aid  of  a  speculum  will  lead  to  a  correct  diagnosis. 
Vulval  varices  may  give  rise  to  serious  bleeding  from  injury 
during  pregnancy,  or  from  rupture  dui^ing  laboui'.  Hcemor- 
rhoids  are  often  produced  or  aggravated  during  the  later 
months  of  pregnancy.  Cramp  in  the  muscles  of  the  legs, 
either  spontaneous  or  when  walking,  is  often  very  trouble- 
some during  the  last  few  weeks,  and  is  probably  due  to 
pressure  upon  the  nerves  of  the  lumbosacral  plexus. 


CARNEOUS    MOLE  143 

The  treatment  of  these  pressure  symptoms  consists,  in 
the  main,  of  rest  in  the  horizontal  position.  In  cases  of 
oedema  careful  examination  of  the  urine  must  of  course  be 
made,  as,  if  albumen  is  present,  the  aspect  of  the  case  is 
entirely  altered.  It  is  better  not  to  undertake  operations 
upon  varicose  veins  or  haemorrhoids  during  pregnancy,  as 
continuation  of  the  pressure  prevents  a  satisfactory  result. 

Uterine  Moles 

The  term  '  mole  '  is  applied  to  an  ovum  destroyed  by 
pathological  conditions  affecting  its  coverings  during  the 
early  months  of  gestation.  Two  kinds  are  recognised,  the 
Blood  Mole  and  the  Hydatidiform  Mole  and  both  may  occur 
in  either  uterine  or  extra-uterine  gestation.  Moles  are  often 
colloquially  termed  '  False  Conceptions.' 

I.  The  Blood  Mole  (Synonyms  :  Carneous  or  Fleshy  Mole, 
Hsematoma  Mole). — The  blood  mole  results  from.the  destruc- 
tion of  the  ovum  by  progressive  or  recurrent  haemorrhage, 
usually  but  not  invariably  occurring  before  the  formation  of 
the  placenta — -i.e.,  during  the  first  three  months  of  pregnancy. 
The  general  structure  of  the  ovum  at  this  period  is  shown  in 
Figs.  11  and  20.  It  is  completely  enveloped  in  the  thick, 
very  vascular,  decidual  membrane  ;  the  chorion  is  separated 
from  this  membrane  by  a  narrow  space  continuous  around 
the  whole  ovum,  termed  the  chorio-decidual  space  ;  this 
space  contains  maternal  blood  and  is  traversed  by  the 
delicate  branching  villi  which  spring  from  the  outer  surface 
of  the  chorion,  and  some  of  which  are  loosely  attached  by 
their  tips  to  the  decidual  surface.  The  morbid  process 
starts  in  hsemorrhage  from  maternal  vessels  into  the  decidual 
tissues,  followed  by  extravasation  of  blood  into  the  chorio- 
decidual  space,  which  will  break  up  and  destroy  the  dehcate 
villi  at  the  affected  spot  (Fig.  61).  A  sudden  and  extensive 
hsemorrhage  of  this  kind  would  no  doubt  cause  rupture  of 
the  decidua  capsularis,  or  complete  detachment  of  the  ovum, 
both  of  which  accidents  would  quickly  lead  to  abortion. 
But  the  blood  mole  is  formed  by  repeated  slight  haemorrhages 
or  by  a  slowly  progressive  haemorrhage,  which  does  not  cause 
rupture  of  the  protective  decidual  covering  of  the  ovum. 
The  effused  blood  is  free  to  surround  the  ovum,  more  or  less 


144 


ABNORMAL   PREGNANCY 


completely,  by  following  the  chorio-decidual  space  ;  hsemor- 
rhage  sometimes  starts  independently  at  different  spots 
(Fig.  61).  The  result  is  the  more  or  less  complete  destruction 
of  the  chorionic  membrane  and  its  villi.  The  amnion,  being 
very  elastic,  is  able  to  resist  the  external  pressure  to  which  it 


Fig.  61. — Tubal  Pregnancy:  Section  of  the  Ov^um  in  situ,  demonstrating 
the  Early  Stage  of  Formation  of  a  Blood  Mole.  Heemorrhage  has 
occiu-red  into  the  Chorio-Decidual  Space,  breaking  up  large  numbers 

of  Villi.     (Couvelaii'e.) 


is  subjected  :  consequently  the  amniotic  sac  is  usually  found 
free  from  blood  in  these  cases.  The  foetus  perishes  and  may 
be  completely  absorbed  ;  sometimes  it  remains  and  is  found 
more  or  less  disorganised  by  maceration  in  the  liquor  amnii. 
Occasionally,  however,  the  amnion  is  totally  destroyed. 
The  effused  blood  is  usually  unequally  distributed  around 
the  ovum,  and  forms  an  irregular  series  of  abrupt  polypoid 


CARNEOUS   MOLE 


145 


elevations  (Fig.  62),  covered  by  the  amnion,  with  deep  inter- 
vening sulci  ;  this  causes  marked  distortion  and  narrowing 
of  the  amniotic  cavity. 

In  Figs.  61  and  62  two  stages  in  the  formation  of  a  blood 
mole  are  shown  ;    the  drawings  were  made  from  cases  of 


Rejnatns    of 
chorio- decidual  space 


Fig.  62. — Tubal  Pregnancy:  Section  of  the  Ovum  in  situ,  demonstrating 
tlie  Late  Stage  of  Formation  of  a  Blood  Mole.    (Couvelaire.) 

tubal  gestation,  and  therefore  they  illustrate  primarily  the 
mode  of  formation  of  a  tubal  mole  ;  but  the  process  is 
probably  identical  with  that  which  occurs  in  the  uterus. 
Opportunities  of  examining  a  uterine  mole  in  situ  very 
seldom  occur,  but  in  the  case  of  a  tubal  mole  they  are  fairly 
common,  as  gravid  tubes  are  usually  removed  by  operation. 
In  Fig.  61  haemorrhage  has  occurred  at  two  distinct  areas  of 
E.M.  10 


146 


ABNORMAL   PREGNANCY 


the  chorio-decidual  space  ;  the  effused  blood  is  bounded 
internally  by  the  unruptured  chorionic  membrane,  and 
within  this  by  the  amnion.  As  there  is  httle  or  no  decidual 
formation  in  the  gravid  tube,  the  haemorrhage  appears  to  be 
limited  externally  by  the  tube-wall.  The  amniotic  sac  and 
the  embryo  appear  to  be  unaffected.  In  Fig.  62  a  later 
stage  of  the  process  is  shown.     Extensive  haemorrhage  has 


Fig.  63. — Fleshy  Mole  :  Four  Weeks'  Gestation,  retained 
until  the  Seventh  Month.  (Charing  Cross  Hospital 
Museum.) 

occurred,  which  entirely  surrounds  the  ovum  ;  it  is  limited 
internally  by  the  amnion  alone,  and  the  amniotic  sac  is 
small  and  distorted,  but  still  contains  a  trace  of  the  body  of 
the  embryo  ;  the  chorionic  membrane  has  been  completely 
destroyed.  Irregular  protuberances  with  intervening  sulci 
are  seen  on  the  amniotic  aspect.  The  haemorrhage  is  almost 
entirely  maternal  in  origin  ;  no  doubt  some  admixture  of 
fcetal  blood  also  occurs,  but  its  amount  must  be  inconsider- 
able, owing  to  the  small  size  of  the  embryo  at  this  period.     A 


CARNEOUS   MOLE  147 

blood  mole  discharged  in  a  fresh  condition — i.e.,  soon  after 
the  occurrence  of  the  haemorrhage — is  sometimes  called  an 
apoplectic  ovum. 

An  ovum  thus  destroyed  may  be  retained  in  utero  for 
many  weeks  or  months  ;  the  effused  blood  then  undergoes 
consolidation  from  absorption  of  its  fluid  constituents,  and 
the  wall  of  the  dead  ovum  becomes  firm  and  '  fleshy  '  in 
consistence  (carneous  or  fleshy  mole,  Fig.  63).  On  section, 
the  wall  of  the  carneous  mole  is  sometimes  seen  to  be  partially 
laminated,  indicating  that  it  has  been  formed  by  repeated 
haemorrhages  ;  sometimes  strands  of  fibrous  tissue  traversing 
it  can  be  recognised,  indicating  remains  of  the  chorion.  On 
microscopic  examination  degenerated  chorionic  villi  im- 
bedded in  blood-clot,  will  be  found  in  it. 

In  a  certain  number  of  fleshy  moles  there  is  a  marked 
disproportion  between  the  size  of  the  amniotic  cavity  and 
the  stage  of  development  of  the  foetus.  This  is  well  shown 
in  Fig.  63,  where  the  foetus  measures  8  mm.  in  length  (three 
to  four  weeks),  while  the  amniotic  sac  measures  2-|  inches  by 
2|  inches  (nine  to  ten  weeks).  A  healthy  foetus  is  never 
found  in  a  carneous  mole.  Occasionally  the  foetus  has 
disappeared  altogether  ;  more  commonly  it  is  dispropor- 
tionately small,  and  is  shrivelled  to  an  extent  which  obscures 
all  its  characteristic  features.  The  umbilical  cord  is  simi- 
larly altered.  These  changes  follow  the  death  of  the  foetus 
and  are  due  to  autolysis,  a  process  by  which  the  albuminous 
constituents  of  the  tissues  are  converted  into  soluble  sub- 
stances, which  are  taken  up  into  the  liquor  amnii  and  thus 
disappear.  Marked  disproportion  in  size  between  the  foetus 
and  the  amniotic  sac  is  probably  due  in  part  to  autolysis  of 
the  foetal  tissues,  and  in  part  to  an  excessive  production  of 
liquor  amnii  (hydramnios).  It  is  possible  that  the  hydram- 
nios  was  present  in  these  cases  before  the  formation  of  the 
mole  began,  the  hsemorrhagic  process  being  started  by  the 
stretching  to  which  the  decidua  was  subjected  by  the 
abnormally  large  ovum.  This  point  is,  however,  still  the 
subject  of  dispute,  and  in  any  case  hydramnios  is  not  to  be 
regarded  as  an  essential  factor  in  the  production  of  a  blood 
mole. 

We  can  only  speculate  upon  the  conditions  which  give 
rise  to  haemorrhage  in  the  early  ovum.     Syphilis,  chronic 

10—2 


148  ABNORMAL   PREGNANCY 

Blight's  disease,  and  endometritis  are  believed  to  be  con- 
cerned in  its  production,  but  upon  inconclusive  evidence. 
The  great  vascularity  of  the  decidual  membrane,  the  imper- 
fect external  support  furnished  by  the  decidua  capsularis  at 
this  period,  and  the  delicacy  of  the  young  chorionic  attach- 
ments, make  it  probable  that  even  in  the  case  of  a  healthy 
ovum  slight  traumatic  disturbances  may  start  the  process. 

The  symptoms  which  attend  the  formation  of  a  uterine 
mole  are  indefinite.  In  most  cases  a  train  of  symptoms,  to 
be  described  later  on  as  those  of  '  threatened  abortion,' 
occur,  which  subside,  and  then  nothing  else  is  noted  until 
the  ovum  is  cast  off.  This  event,  which  may  take  place 
within  a  few  weeks  or  be  delayed  for  many  months,  is  known 
as  a  '  missed  abortion.'  The  process  does  not  differ  in  any 
respect  from  that  subsequently  to  be  described  as  '  inevitable 
abortion.'  The  diagnosis  is  naturally  a  matter  of  some  diffi- 
culty, and  can  really  only  be  solved  by  the  expulsion  of  the 
mole.  From  the  clinical  standpoint  these  cases  come  under 
observation  as  cases  of  abortion,  and  are  to  be  treated  as 
such.  Interference  is  seldom  required,  but  if  the  uterine 
discharge  should  become  offensive  (infection  of  the  ovum), 
the  treatment  consists  in  dilating  the  cervix  and  clearing  out 
the  uterine  contents  in  the  manner  described  under  the  treat- 
ment of  abortion. 

II.  The  Hydatidiform  Mole  (Synonyms  :  Vesicular  Mole  ; 
Hydatidiform  Degeneration  of  the  Chorion). — This  condition 
is  a  disease  of  young  chorionic  villi,  characterised  by  the 
formation  of  immense  numbers  of  irregular  clusters  and 
chains  of  cysts  which  vary  in  size  from  extreme  minuteness 
up  to  f  inch  in  diameter.  Cases  have,  however,  been 
recorded  in  which  the  largest  vesicles  measured  \\  inches  in 
long  diameter.  The  superficial  resemblance  of  these  cysts 
to  hydatids  originated  the  name  by  which  this  condition  is 
known,  but  it  must  be  understood  that  the  hydatidiform 
mole  has  really  nothing  in  common  with  echinococcal  cystic 
disease.  The  naked-eye  appearance  of  this  mole  is  so 
characteristic  that  its  recognition  is  very  easy. 

The  disease  has  been  observed  as  early  as  the  third  week 
of  pregnancy,  and  in  such  cases  the  whole  of  the  chorionic 
membrane,  being  villous,  may  be  affected  in  the  manner 
represented  in  Fig.  64.     It  probably  begins  in  all  cases  at  a 


VESICULAR   MOLE  149 

comparatively  early  period,  for  it  is  quite  exceptional  for  any 
trace  of  the  foetus  or  the  amniotic  sac  to  be  found.  As  a  rule 
the  contour  of  the  ovum  is  completely  lost,  and  a  mass  of 
vesicles  is  formed,  having  no  definite  arrangement  whatever 
and  assuming  the  contour  of  the  distended  uterine  cavity. 


Fig.  64. — Hydatidiform  Mole  (Diagrammatic) :  the  Entire  Chorion  is 
affected  by  the  Disease ;  the  Amniotic  Sac  is  seen  in  the  centre. 
(Bumm.) 

The  formation  of  vesicles  may  be  so  abundant  as  to  produce 
a  mass  weighing  4  to  5  pounds.  The  general  relations  of  the 
mole  are  well  shown  in  Fig.  65,  which  represents  the  mole 
as  seen  in  situ,  the  uterus  having  been  removed  by  supra- 
vaginal hysterectomy.  The  cystic  villi  are  closely  packed 
together,  and  the  interstices  between  them  are  filled  with 
blood  derived  from  the  maternal  decidua.     The  villi  are 


150 


ABNORMAL   PREGNANCY 


attached  to  the  uterine  wall  in  the  greater  part  of  its  extent ; 
on  the  right  of  the  uterus,  however,  a  narrow  space  filled 
with  blood -clot  lies  between  the  mole  and  the  uterine  wall  ; 
this  represents  the  decidual  space.     The  internal  os  is  partly 


Fig.  65. — Vesicular  Mole  in  situ.     The  Uterus  was  removed 
by  Supra- vaginal  Hysterectomy.     (Haig  Ferguson.) 


dilated,  allowing  the  lower  pole  of  the  cystic  mass  to  protrude 
into  the  cervical  canal. 

Occasionally  the  disease  may  begin  at  a  later  period  when 
the  formation  of  the  placenta  is  advanced,  and  the  greater 
part  of  the  chorion  is  non- villous.  The  degenerative  changes 
are  then  usually  partial,  and  affect  a  portion  of  the  placenta 
only,  so  that  the  general  shape  of  the  organ  may  be  retained 
and  the  body  of  the  foetus  be  recognisable.     This  is  well 


VESICULAR  MOLE 


151 


illustrated  in  Fig.  66,  which  represents  a  placenta  infiltrated 
by  haemorrhage  and  partially  affected  by  vesicular  degenera- 


FiG.  66. — Placenta  with,  extensive  Hgemorrhage  and  Vesicular 
Degeneration  of  the  Chorion.  Note  the  Cysts  imbedded 
in  Blood-clot.     (Charing  Cross  Hospital  Museum.) 

tion.     A  considerable  number  of  instances  have  now  been 
recorded  in  cases  of  extra-uterine  gestation. 


152  ABNORMAL  PREGNANCY 

The  vesicles  themselves  are  oval  or  globular  grape-like 
bodies,  pale  yellowish  in  colour,  and  semi-translucent.  Each 
vesicle  is  stalked,  the  jjedicle  being  delicate  and  short.  The 
vesicles  may  be  arranged  in  chains,  or  in  clusters  of  irregular 
shape  ;  when  pricked  or  incised  they  exude  a  thin  fluid.  The 
decidua  in  cases  of  vesicular  mole  is  usually  abnormally  thick, 
and  shows  considerable  round-celled  infiltration  on  micro- 
scopic examination.  This  may,  perhaps,  be  regarded  as 
a  defensive  change  which  enables  the  decidua  to  offer 
greater  resistance  to  the  eroding  action  of  the  chorionic 
epithelium  and  thus  to  protect  the  uterine  wall  against 
abnormal  penetration. 

The  microscopic  characters  of  the  vesicles  present  the 
curious  association  of  abnormally  active  proliferation  of  both 
the  syncytial  and  cellular  layers  of  the  chorionic  ej)ithelium, 
with  degeneration  of  the  connective-tissue  stroma.  The 
vesicles  all  possess  a  complete  epithelial  wall.  In  the  larger 
vesicles  the  stroma  and  the  blood-vessels  are  completely 
destroyed,  and  only  a  few  degenerated  nuclei  persist  ;  the 
contents  are  entirely  fluid.  In  the  smallest  vesicles  the 
stroma  may  be  fairly  normal,  in  those  of  medium  size  a  layer 
of  altered  and  compressed  connective  tissue  may  be  found 
immediately  under  the  epithelium,  the  centre  of  the  vesicle 
containing  only  fluid  (Fig.  67).  Mucoid  (myxomatous) 
degeneration  was  originally  supposed  to  be  the  nature  of 
these  changes  in  the  stroma,  but  it  has  now  been  established 
that  the  fluid  found  in  the  vesicles  contains  no  mucin  ;  some 
other  form  of  colliquative  necrosis  is  therefore  the  probable 
cause.  The  epithelial  covering  of  many  vesicles  shows 
remarkably  active  proliferation  of  the  syncytial  layer.  In 
others  the  epithehum  shows  no  abnormal  changes  whatever. 
In  Fig.  67  are  seen  numerous  buds  and  processes  springing 
from  the  syncytium,  and  also  isolated  sections  of  such  pro- 
cesses springing  from  neighbouring  villi  (syncytial  buds). 
The  change  in  both  the  epithelium  and  the  stroma  will  be 
best  appreciated  by  comparing  Fig.  67  with  Fig.  22,  repre- 
senting the  same  structures  in  a  young  normal  viUus. 
Unusually  active  proliferation  of  the  ceUs  of  Langhans  is 
also  generally  found.  This  abnormal  epithelial  proliferation, 
although  not  of  universal  distribution,  forms  a  characteristic 
feature  of  these  moles. 


VESICULAR   MOLE 


153 


An  important  result  of  this  abnormal  activity  on  the  part 
of  the  chorionic  epithelium  is  that  it  possesses  powers  of  pene- 
trating the  uterine  wall  which  exceed  those  of  normal  villi. 
The  eroding  properties  of  this  tissue  have  been  already 
referred  to  in  connection  with  the  normal  ovum.  It  has 
been  generally  believed  from  clinical  observations  that  the 


bjncytial  bud 


^^'/^^          .     '^?V/   .,  %.''!'%><  Cells  Of 
^'ML  " —  <  t    •A'V'k-  f—^ ?■)  ]•>  ''"'^  ^Langhatis's  layer 


Fig.  67. — Hydatidiform  Mole  ;    Section  through  a  Chorionic  Villus. 

cystic  villi  eroded  the  uterine  wall  to  an  unusual  extent, 
causing  dangerous  thinning.  A  few  cases  have  been 
recently  recorded  in  which  a  mole  was  examined  in  situ  after 
the  removal  of  the  uterus  from  the  body.  These  exact 
observations  do  not  support  this  view,  for  the  uterine  wall 
has  not  been  found  abnormally  thin  in  any  instance.  But 
there  is  no  doubt  that  in  certain  instances  the  eroding  power 
of  the  villi  is  so  great  as  to  cause  spontaneous  perforation  of 


154  ABNORMAL   PREGXAXCIZ 

the  uterine  wall,  leading  usually  to  death  from  haemorrhage 
or  peritonitis.  This  variety  is  known  as  the  perforating  or 
malignant  hydaticliform  mole  ;  it  is  closely  aUied  in  histological 
characters  to  chorion  epitheUoma  (deciduoma  malignum), 
and  is  frequently  followed  after  an  interval  by  the  appear- 
ance of  this  formidable  new  growth  (see  p.  607).  The 
propeii:y  of  destroying  healthy  tissues  is  one  of  the  chief 
characteristics  of  mahgnant  disease,  and  quite  justifies  the 
term  '  mahgnant  '  being  apj)lied  to  this  form  of  mole.  With 
the  remarkable  activity  of  the  chorionic  epithelium  must  be 
contrasted  the  fact  that  the  degenerated  villi  are  completely 
devascularised  and  the  embrj^o  destroyed.  This  fact  well 
illustrates  the  truly  parasitic  nature  of  the  degenerated  villi. 
They  receive  no  blood  supply  from  the  foetus,  but  are 
nourished  by  the  maternal  blood  with  which  they  are  in 
contact,  and  are  thus  enabled  to  grow  and  to  proliferate. 
It  has  been  already  pointed  out  that  the  probable  source  of 
the  nutrition  of  healthy  chorionic  viUi  is  also  the  maternal 
blood  of  the  intervillous  spaces.  In  the  vesicular  mole 
there  is  no  intervillous  maternal  circulation,  but  at  the  same 
time  a  considerable  quantity  of  maternal  blood  is  found 
between  the  cysts,  the  source  of  which  is  necessarily  the 
uterine  wall. 

Nothmg  is  definitely  laiown  as  to  the  causation  of  the 
hydatidif orm  mole,  though  there  has  been  much  speculation 
about  it.  Some  authorities  beheve  that  an  unhealthy  con- 
dition of  the  decidua  induces  the  morbid  change  in  the 
chorion,  but  others  consider  that  it  arises  primarily  in  the 
chorion  itself.  It  appears  to  be  more  reasonable  to  regard 
it  as  an  embryonic  disease,  and  this  view  is  supported  by 
the  fact  that  in  twin  pregnancy  it  sometimes  affects  one 
ovum  only.  If  the  cause  lay  in  the  decidua,  both  ova  would 
certainly  be  affected.  It  may  occur  at  any  time  in  the  repro- 
ductive period,  but  is  most  commonly  met  with  in  the 
decennial  periods  20  to  30  and  40  to  50.  It  is  a  distirictly 
rare  condition,  occurring  probably  in  about  1  in  2,000  to 
2,500  pregnancies. 

Within  recent  years  it  has  been  pointed  out  that  cystic 
tumours  of  the  ovary  occur  in  association  with  vesicular 
moles  with  such  frequency  that  a  casual  connection  between 
the  two  may  be  considered  probable.     Thus,  Kromer  has 


VESICULAR   MOLE  155 

recorded  a  series  of  seventeen  moles,  in  ten  of  which  the 
presence  of  an  ovarian  tumour  was  clinically  recognised. 
Further,  it  has  been  shown  that  these  ovarian  tumours  are 
usually  cysts  which  have  arisen  in  the  corpus  luteum,  and 
are  in  some  way  the  result  of  abnormal  proliferative  activity 
of  the  lutein  tissue.  It  has  accordingly  been  suggested  that 
perverted  ovarian  activity  may  prove  to  be  an  important 
factor  in  the  production  of  these  moles,  but  in  the  meantime 
it  cannot  be  said  that  this  theory  has  been  satisfactorily 
proved. 

Clinical  Features. — Two  symptoms  are  commonly  met 
with  in  this  condition  :  (1)  undue  enlargement  of  the  uterus  ; 
(2)  heemorrhagic  discharge.  They  always  begin  in  the  first 
half  of  pregnancy. 

(1)  Undue  enlargement  of  the  uterus,  although  usual,  is 
not  invariably  found.  Occasionally  the  size  corresponds  to 
the  presumptive  duration  of  pregnancy  :  occasionally  the 
uterus  is  disproportionately  small.  In  the  great  majority, 
however,  it  is  disproportionately  large  ;  thus  the  fundus  may 
extend  up  to  the  umbilicus  three  months  after  the  cessation 
of  the  last  regular  monthly  period  ;  a  less  pronounced  dis- 
parity than  this  is,  however,  more  common.  But  it  must 
be  remembered  that  over-enlargement  of  the  uterus  at  the 
third  or  fourth  month  may  occur  from  other  causes.  The 
large  uterus  occupies  the  normal  mesial  position  of  the  womb. 
In  exceptional  cases  it  has  been  described  as  extending  up  to 
the  ensiform  cartilage  ;  but  it  not  infrequently  reaches  con- 
siderably higher  than  the  umbilicus.  It  possesses  a  peculiar 
doughy  consistence.  It  is  exceptional  for  the  foetal  heart- 
sounds  to  be  heard,  even  when  the  uterus  is  of  the  size  of  six 
or  seven  months'  pregnancy,  because,  except  in  rare  instances, 
there  is  no  foetus.  Vesicular  degeneration  sometimes,  how- 
ever, in  a  twin  pregnancy  affects  one  ovum  only,  and  then  of 
course  the  heart  of  the  surviving  foetus  may  be  heard.  As  a 
rule  the  uterine  souffle  cannot  be  detected,  nor  can  inter- 
mittent contractions  be  felt. 

(2)  The  discharge  usually  appears  during  the  third  or 
fourth  month,  i.e.,  at  a  time  when  the  disease  has  been 
already  in  existence  for  some  weeks.  It  is  commonly  small 
in  amount,  more  or  less  continuous,  thin  and  watery  in 
character,  reddish  or  reddish-brown  in  colour,  and  unattended 


156  ABNORMAL   PREGNANCY 

by  pain.  Severe  hsemorrhage  is  rarely  met  with  except 
during  the  process  of  abortion,  when  it  may  be  very  profuse. 
In  rare  instances  the  discharge  may  possess  characters  which 
are  pathognomonic,  detached  vesicles  being  found  in  it  ; 
but  this  is  uncommon  and  must  not  be  anticipated.  Some- 
times the  discharge  soUdifies,  forming  a  red  jelly  in  which 
pale  vesicles  may  be  found. 

The  over- enlargement  of  the  uterus  is  of  course  due  to 
the  bulk  of  the  diseased  ovum,  which  may  be  enormous  ;  its 
peculiar  consistence  is  due  to  the  absence  of  the  amniotic 
fluid  sac,  which  gives  to  the  normal  gravid  uterus  its  charac- 
teristic elasticity.  The  hsemorrhage  is  probably  occasioned 
by  the  detachment  of  vesicles  from  the  uterine  wall,  and  by 
rupture  of  vesicles  ;  the  discharge  therefore  consists  partly 
of  maternal  blood  and  partly  of  the  fluid  contents  of  rup- 
tured vesicles.  After  the  hsemorrhage  has  persisted  for 
a  variable  period,  spontaneous  abortion  almost  always 
occurs. 

The  general  condition  of  a  patient  with  a  vesicular  mole  is 
often  unfavourably  affected  to  an  extent  not  to  be  accounted 
for  bj^  the  amount  of  hsemorrhage  which  has  occurred. 
Morning  sickness  is  often  unusually  severe,  and  toxsemic 
symptoms  of  a  mild  type  are  sometimes  recognised.  In  a 
certain  proportion  of  cases,  at  present  undetermined,  chorion- 
epithelioma  supervenes,  either  immediately  upon  the  evacua- 
tion of  the  mole  or  after  an  interval.  In  Kromer's  seven- 
teen cases,  chorion-epithelioma  subsequently  occurred  in 
seven,  but  this  is  almost  certainly  an  unusually  high  pro- 
portion. 

Diagnosis  is  often  uncertain,  and  can  only  be  settled  by 
the  discovery  of  vesicles  ;  if  none  are  discharged  spon- 
taneously, the  finger  may  sometimes  feel  them  in  the  cervical 
canal  if  the  internal  os  is  a  Httle  dilated.  In  the  absence  of 
this  sign  it  may  be  said  that  marked  over-enlargement  of  the 
uterus,  with  persistent  or  repeated  hsemorrhage  at  the  third 
or  fourth  month  of  pregnancy,  is  suggestive  of  a  hydatidi- 
form  mole. 

Treatment.- — This  consists  in  all  cases  in  artificial  evacua- 
tion of  the  uterus.  Spontaneous  abortion  of  a  hydatidiform 
mole  is  a  very  long  and  tedious  process,  resulting  in  consider- 
able hsemorrhage  ;    being  almost  invariably  incomplete,  it 


VESICULAR   MOLE  157 

must  be  terminated  by  interference.  The  uterus  in  these 
cases  appears  to  be  unable  to  expel  its  contents,  and  it  is 
therefore  best,  when  the  diagnosis  has  been  made,  to  evacuate 
it  without  delay.  This  procedure  is  fully  described  in  con- 
nection with  the  induction  of  abortion  (p.  653).  The  cervix 
is  usually  slightly  patulous,  and  can  readily  be  dilated  suffi- 
ciently to  admit  one  finger  ;  if  more  room  is  desired  the  cer- 
vix must  be  divided  as  described  on  p.  658.  With  the  finger, 
aided  by  a  pair  of  blunt  forceps  or  ovum  forceps,  the  mass  of 
vesicles  can  be  broken  up  and  removed  piecemeal.  What 
seems  at  first,  on  account  of  the  size  of  the  uterus,  a  task 
almost  impossible  for  the  fingers  alone,  becomes  easier  as 
the  process  advances,  the  uterus  gradually  diminishing  in 
size  so  as  to  bring  the  fundus  within  reach.  The  curette  is 
unnecessary,  and  even  in  experienced  hands  may  lead  to 
perforation  of  the  uterine  wall.  Care  should  be  taken  to 
detach  all  the  vesicles  and  decidua  from  every  part,  and  the 
uterine  cavity  should  then  be  thoroughly  douched  with  a 
weak  antiseptic  solution  and,  if  retraction  is  unsatisfactory, 
packed  with  bismuth  gauze.  There  are  special  risks  in  the 
puerperium  of  sepsis,  sub-involution,  and,  remotely,  of  the 
development  of  chorion-epithelioma. 


Decidual  Endometritis 

Acute  decidual  endometritis  has  been  observed  in  cases 
of  ascending  gonorrhoea  in  pregnant  women,  the  gonococcus 
having  been  demonstrated  in  the  decidual  membrane.  So 
far  as  we  know,  this  is  the  only  variety  of  acute  inflammation 
of  the  decidua  arising  spontaneously  during  pregnancy  ;  but 
acute  septic  inflammation  from  operative  interference  may, 
of  course,  also  be  met  with.  Chronic  decidual  endometritis 
is  more  common,  and  is  believed  to  result  from  implantation 
of  the  ovum  upon  an  unhealthy  endometrium.  The  mem- 
brane is  unusually  thick  and  fleshy,  and  often  shows  numer- 
ous small  cysts  beneath  the  epithelium,  which  arise  from 
irregular  dilatation  of  the  deep  parts  of  the  uterine  glands. 
Although  decidual  endometritis  is  undoubtedly  a  genuine 
cause  of  abortion,  its  clinical  recognition  is  impossible  in  the 
present  state  of  our  knowledge  ;   diagnosis  can  only  be  made 


158  ABNORMAL  PREGNANCY 

from  examination  of  the  membrane  after  its  discharge  from 
the  uterus. 

HydrorrJioea  Gravidarum  and  Decidual  Endometritis. — 
Hydrorrhoea  gravidarum  is  the  term  apphed  to  a  condition 
in  which  a  discharge  of  watery  fluid  from  the  gravid  uterus 
occurs  intermittently  in  consideral^le  amount,  from  the 
second  or  third  month  of  pregnancy,  and  may  continue  to 
term.  In  some  cases  a  small  amount  of  blood  is  mixed  with 
the  watery  fluid.  It  is  a  rare  condition,  and  is  often  asso- 
ciated with  foetal  malformation.  Three  possible  sources  for 
such  a  discharge  may  be  pointed  out.  Firstly,  it  may  be  a 
leakage  from  the  amniotic  sac  (hydrorrhoea  amnialis)  ; 
secondly,  it  may  come  from  an  adventitious  collection  of 
fluid  between  the  chorion  and  amnion,  resulting  from  im- 
perfect fusion  of  these  membranes  ;  thirdly,  it  may  come 
from  the  decidual  space.  In  all  probability  the  latter  is  the 
most  common  cause,  and  although  it  must  be  admitted  that 
direct  proof  is  wantmg,  decidual  endometritis  appears  to 
offer  the  best  explanation  of  the  occurrence.  A  reference  to 
Figs.  14  and  44  will  recall  the  fact  that  in  the  lower  part  of 
the  early  gravid  uterus  there  is  a  small  cavity  bounded  on  all 
sides  by  decidua,  and  termed  the  decidual  space.  In  decidual 
endometritis  a  watery  fluid  such  as  that  of  hydrorrhoea  may 
possibly  be  secreted,  which  accumulates  in  this  space  and  is 
discharged  from  time  to  time  through  the  cervix,  when  the 
amount  becomes  large.  The  existence  of  pockets  of  fluid  in 
this  position  has  been  recently  demonstrated  by  Duclos  in 
the  uterus  of  a  woman  who  died  during  pregnancy,  and  who 
had  suffered  from  hydrorrhoea  with  slight  haemorrhage. 
Normally  the  decidual  space  becomes  obliterated  by  fusion 
of  the  decidua  vera  and  decidua  capsularis  at  the  end  of  the 
fourth  month,  but  when  the  membranes  are  unhealthy  their 
fusion  may  be  delayed  or  prevented  ;  the  decidual  space  may 
then  persist  and  the  hydrorrhoea  continue  until  term.  The 
expelling  force  may  be  considered  to  be  uterine  contractions 
of  unusual  power,  reflexly  excited  by  the  presence  of  the 
accumulating  fluid.  The  condition  is  not  amenable  to 
treatment  of  any  kind,  and  is  not  of  much  chnical  importance 
except  when  due  to  leakage  of  liquor  amnii  ;  it  then  leads  to 
premature  labour  attended  by  many  of  the  difficulties 
arising  from  ante-partum  rupture  of  the  membranes. 


HYDRAMNIOS  159 

Diseases  of  the  Membranes,  Placenta,  and  Foetus 

Hydramnios  (Synonym  :  Polyhydramnios). — ^This  con- 
dition consists  in  the  formation  of  an  excess  of  liquor  amnii. 
The  amount  of  liquor  amnii  at  term  which  may  be  regarded 
as  normal  varies  considerably  (p.  49)  ;  it  is  probable  that 
only  quantities  exceeding  4  pints  would  be  clinically  recog- 
nisable as  hydramnios.  The  fluid  shows  no  abnormal 
characters,  but  it  may  attain  the  enormous  bulk  of  6  gallons. 

The  causation  of  hydramnios  is  by  no  means  capable  of 
simple  explanation.  It  must  be  recollected  that  the  con- 
dition is  normal  during  the  first  eight  weeks  of  gestation, 
and  occurs  in  an  exaggerated  form  in  many  cases  of  carneous 
mole.  When  occurring  in  the  later  months,  it  is  occasionally 
associated  with  morbid  maternal  conditions  such  as  dropsy 
from  cardiac  or  hepatic  disease,  and  more  frequently  with 
developmental  anomalies  of  the  foetus.  It  is  not  clear, 
however,  that  these  associations  can  be  regarded  as  the 
cause  of  the  hydramnios.  In  complete  spina  bifida  escaping 
cerebro-spinal  fluid  may  assist  the  accumulation  of  an  excess 
of  liquor  amnii,  but  the  amount  of  cerebro-spinal  fluid  is 
probably  too  small  to  make  any  serious  difference. 

It  is  quite  possible  that  under  normal  conditions  there 
may  be  both  a  formation  and  an  absorption  of  liquor  amnii, 
and  hydramnios  may  therefore  conceivably  be  brought 
about  by  deficient  absorption  as  well  as  by  excessive  pro- 
duction. In  some  cases  of  hydramnios  extreme  torsion  or 
thrombosis  of  the  umbilical  vein  has  been  found  ;  these 
conditions  may  lead  to  excessive  transudation  of  fluid 
through  the  walls  of  the  large  vessels  on  the  foetal  surface  of 
the  placenta.  Whatever  may  be  the  precise  mechanism  of 
its  production,  certain  considerations  make  it  probable  that 
hydramnios  is  usually  due  to  a  foetal,  not  a  maternal  cause : 
(1)  The  mother  is  usually  healthy;  (2)  the  foetus  is  fre- 
quently deformed,  or  shows  some  abnormality  of  develop- 
ment; (3)  it  frequently  occurs  in  twin  pregnancy,  affecting 
only  one  amniotic  sac  ;  (4)  the  liquor  amnii  is  certainly 
an  embryonic  product  when  first  formed  in  the  ovum. 
Hydramnios  is  more  common  in  multiparse  than  primi- 
gravidse  ;  in  75  per  cent,  of  cases  the  foetus  is  of  the  female 
sex  ;  and  it  has  been  observed  in  extra-uterine  gestation. 


160  ABNORMAL   PREGNANCY 

As  usually  met  with,  hydramnios  is  a  chronic  condition 
which  does  not  become  clinically  recognisable  until  the 
fourth  or  fifth  month  of  pregnancy,  and  is  slowly  progressive. 
Its  actual  onset  is,  of  course,  earlier  than  this.  Occasionally, 
however,  it  assumes  an  acute  form,  an  enormous  quantity  of 
fluid  being  formed  within  a  few  weeks.  The  symptoms  to 
which  it  gives  rise  are  due  to  the  size  of  the  uterus  ;  when  the 
enlargement  has  occurred  rapidly,  as  in  the  acute  form,  the 
symptoms  are  correspondingly  severe  ;  in  the  chronic  form 
much  greater  toleration  of  the  large  uterus  is  met  with. 
Slight  degrees  of  hydramnios  usually  escape  recognition, 
especially  if  associated  with  twin  pregnancy.  The  abdominal 
enlargement  is  often  extreme,  indeed  hydramnios  may  yield 
one  of  the  largest  abdominal  swellings  ever  met  with. 
Relatively  to  the  size  of  the  abdomen,  the  associated 
symptoms  are  slight,  consisting  chiefly  of  some  embarrass- 
ments of  respiration  and  cardiac  action,  especially  in  the 
recumbent  position,  so  that  the  patient  must  sleep  well 
propped  up  in  bed.  There  may  also  be  pain  and  slight 
anasarca  of  the  lower  extremities,  and,  of  course,  inability 
for  physical  exertion  of  all  kinds.  There  is  no  special  ten- 
dency to  the  occurrence  of  albuminuria.  Labour  usually 
comes  on  prematurely,  with  ante-partum  rupture  of  the 
membranes,  which  brings  immediate  relief. 

The  physical  signs  yielded  by  the  uterus  in  a  case  of  well- 
marked  hydramnios  differ  from  those  of  the  normal  gravid 
uterus  as  follows  :  (1)  its  size  is  disproportionately  large  ; 
(2)  a  fluid  thrill  may  be  obtained  in  all  directions  ;  (3)  some- 
times the  presence  of  the  foetus  cannot  be  recognised  either 
by  palpation  or  auscultation  ;  (4)  in  slighter  degrees  the 
foetal  head  may  be  felt,  but  not  the  trunk  or  the  limbs. 
Signs  of  pregnancy  will,  however,  be  found  in  the  active 
condition  of  the  mammary  glands  (primigravidse),  the 
characteristic  softening  of  the  cervix,  and  a  history  of  several 
months'  amenorrhoea.  These  points  should  deter  an  observer 
from  attributing  the  abdominal  swelling  to  an  ovarian  cyst 
or  to  ascites.  A  large  ovarian  cyst  may  be  occasionally 
associated  with  pregnancy  ;  the  differential  diagnosis  from 
hydramnios  is  then  more  difficult,  and  will  depend  upon 
the  recognition,  in  the  former,  of  two  distinct  abdominal 
swellings  together  with  the  presumptive  signs  of  pregnancy  ; 


HYDR  AMNIOS  161 

the  physical  signs  of  one  of  the  abdominal  swellings  will 
correspond  with  those  of  the  normal  gravid  uterus. 

There  are  no  means  known  to  us  of  controlling  the  pro- 
duction or  absorption  of  liquor  amnii,  and  this  condition 
is  therefore  not  amenable  to  treatment.  If  the  pressure 
symptoms  become  severe,  premature  labour  must  be  pro- 
voked, the  method  of  choice  being  rupture  of  the  membranes  ; 
this  is  more  likely  to  be  required  in  the  acute  than  in  the 
chronic  form.  The  weakening  of  the  uterine  muscle  from 
over-distension  leads  to  uterine  inertia  and  its  attendant 
risks  in  labour  (p.  443). 

Oligo-Hydramnios. — In  this  condition  the  liquor  amnii 
is  deficient  in  amount,  and  there  may  be  only  a  few  ounces  of 
fluid  in  the  amniotic  sac.  Its  causation  is  unknown,  and  it 
does  not  give  rise  to  any  maternal  symptoms.  The  foetus 
may  show  various  deformities  caused  by  amniotic  adhesions. 

Oligo-hydramnios  may  give  rise  to  certain  of  the  less 
important  foetal  deformities  through  the  insufficient  space 
which  it  affords  for  free  exercise  of  the  limbs.  In  this  way 
club-foot,  spinal  curvature,  wry  neck,  or  ankylosis  of  joints 
may  conceivably  be  brought  about.  It  is,  however,  by 
means  of  amniotic  adhesions  that  still  more  important 
deformities  are  occasioned.  These  consist  in  the  forma- 
tion of  intimate  union  between  the  amnion  and  some  part 
of  the  skin  of  the  foetus  ;  the  result  is  the  production  of 
surface  deformities  in  the  affected  parts. 

Occurring  upon  the  scalp,  encephalocele  may  result  ; 
when  surrounding  a  limb,  strangulation  followed  by  spon- 
taneous amputation  may  occur  ;  sometimes  the  adhesion 
may  strangulate  the  cord,  causing  the  death  of  the  foetus. 
Amniotic  adhesions,  while  usually  associated  with  deficiency 
of  liquor  amnii,  sometimes  occur  when  the  amount  of  fluid 
is  normal  or  is  excessive. 

Diseases  of  the  Placenta. — Comparatively  little  progress 
has  been  made  with  the  study  of  the  morbid  conditions  of  the 
placenta,  for  the  reason  that  the  normal  structure  of  the 
organ  at  different  periods  of  gestation  has  only  recently  been 
systematically  worked  out.  Most  of  the  earlier  accounts  of 
placental  diseases  must  be  rejected  because  the  writers  were 
ignorant  of  these  fundamental  details,  Thus  '  placentitis  ' 
was  at  one  time  thought  to  be  a,  lesiQU  of  frequent  occurrence, 
E.M.  11 


162 


ABNORMAL   PREGNANCY 


but  it  is  now  known  that  inflammation  rarely,  if  ever,  occm^s 
in  the  jolacenta  ;  again,  conditions  such  as  '  infarctions,' 
which  were  once  regarded  as  sj^hihtic  gummata,  are  now 
known  to  be  non-syphilitic. 

Anomalies  of  Size  and  Shape. — The  placenta  is  sometimes 
divided  unequally  into  lobes  or  segments,  which  are  united 
by  large  vessels  (umbilical)  running  in  the  membranes  which 
connect  them.  There  may  be  two  lobes  {placenta  bipartita) 
(Fig.  68),  three  lobes  {placenta  tripartita),  or  more  than  three 


Fig.  68.— Placenta  Bipartita. 

Xote  the  bifurcation  of  the  umbilical  vessels  at  the  point  of  insertion  of  the  cord. 

{placenta  multiloba).  More  important  than  these  is  another 
variety  of  divided  j)lacenta,  called  the  placenta  succenturiata 
(Figs.  69  and  55).  In  this  form  one  or  two  small  outlying 
portions  of  placenta,  cii'cular  or  oval  in  shape,  are  present  ; 
they  are  connected  with  the  mam  placenta  by  small  vessels 
running  in  the  membranes,  and  are  very  Hable  to  be  left  in 
the  uterus  after  labour  ;  they  may  thus  give  rise  to  post- 
partum haemorrhage,  and  (indnectly)  in  the  puerperium  to 
septic  troubles.  Very  rarely  the  placenta  is  formed  over  the 
whole   area   of  the   chorion,   the  usual  differentiation  mto 


PLACENTAL    DISEASES 


163 


chorion  frondosum  and  chorion  Iseve  not  taking  place.  This 
is  known  as  the  placenta  diffusa  :  it  is  the  natural  form  in 
certain  animals — e.g.,  the  sow  and  the  mare. 

Anomalies    of    the    Umbilical    Insertion. — The    cord    is 
usually  attached  to  the  placenta  about  its  centre  ;    but  the 


Edge  of 
'placenta 


Fig.  69. — A  Portion  of  Placenta  and  Membranes,  showing  a  Small 
Placenta  Succenturiata.     (Charing  Cross  Hospital  Museum.) 


insertion  may  be  excentric,  lateral,  or  marginal,  the  latter 
being  called  the  battledore  placenta  (Fig.  70).  More  important 
practically  is  the  comparatively  rare  anomaly  of  the  insertion 
of  the  cord  into  the  membranes  altogether  outside  the 
placental  margin — the  velamentous  placenta  (Fig.  71).  Very 
large  vessels,  constituting  the  primary  divisions  of  the 
umbilical  arteries  and  vein,  then  run  beneath  the  amnion, 

11—2 


164 


ABNORMAL   PREGNANCY 


from  the  point  of  insertion  to  the  placental  margin,  and  are 
liable  to  become  injured  during  labour  by  compression,  or  by 
rupture  of  the  membranes  which  enclose  them.  The  latter 
accident   is   only   liable   to    occur   when   these   vessels   are 


Fig.  70. — Battledore  Placenta. 

The  umbilici]  cord  is  ijisei  ted  close  to  the  placental  margin. 

situated  in  the  position  where  the  membranes  rupture  at  the 
end  of  the  second  stage  of  labour. 

Placental  anomalies  cannot,  as  a  rule,  be  recognised  until 
after  delivery.  An  exception  to  this  rule  is  the  case  of 
the  velamentous  insertion  which  may  be  recognised  during 
labour  if  the  vessels  chance  to  cross  the  lower  pole  of  the 
ovum.  A  case  of  this  kind  has  been  recorded  by  Williamson, 
in  which  he  delivered  the  child  by  Csesarean  section,  in  ord^r 


PLACENTAL   DISEASES 


165 


to   avoid  the  risks   of  fatal  foetal  hsemorrhage   when   the 
membranes  rujDtured. 

Pathological   Infarction   of  the   Placenta. — It    has    been 
already  stated  that,  during  the  last  two  months  of  intra- 


FiG.  71. — Velamentous  Placenta. 

The  amnion  has  been  stripped  oft. 


uterine  life,  certain  age-changes  occur  in  the  foetal  portion 
of  the  placenta  which  result  in  the  formation  of  small  solid 
bodies,  termed  '  infarcts,'  in  the  spongy  placental  substance 
(p.  45).  In  connection  with  the  albuminuria  of  pregnancy, 
and  with  chronic  nephritis  in  pregnancy,  changes  of  a  similar 


166  ABNORMAL  PREGNANCY 

nature,  but  much  more  extensive,  and  occurring  earlier  in 
gestation,  are  met  with.  These  changes  are  probably  impor- 
tant factors  in  the  causation  of  the  heavy  foetal  mortahty 
which  attends  these  disorders.  In  such  cases  recent  haemor- 
rhages into  the  placental  substance  are  also  often  found,  and 
are  j)robably  due  to  rupture  of  vessels  in  the  decidua. 

Degeneration  of  the  Placenta. — ^Fatty,  calcareous,  and 
cystic  degenerations  are  often  met  with  in  the  placenta. 
Fatty  and  calcareous  degenerations  are  usually  combined, 
and  are  constantly  found  in  infarcted  areas  ;  it  is  probably 
true  that  primary  fatty  degeneration  does  not  exist  in  the 
placenta,  and  in  no  circumstances  is  it  directly  related  to 
sj^hilis.  Extensive  calcareous  degeneration  of  the  uterine 
surface  of  the  placenta  is  common  when  gestation  has  been 
unduly  prolonged  (post-maturity).  Cystic  degeneration 
results  in  the  formation  of  small  sub-amniotic  cysts  upon  the 
foetal  surface  of  the  placenta.  They  are  frequently  multiple  ; 
they  are  never  large,  and  do  not  affect  the  functional  activity 
of  the  organ.  Hydatidiform  degeneration  has  been  already 
described. 

Tubercle  of  the  Placenta  is  very  rare,  but  it  has  been  shown 
to  occur  occasionally  in  women  affected  with  acute  general 
tuberculosis  or  advanced  chronic  phthisis.  The  tuberculous 
deposits  may  be  found  either  in  the  decidua,  upon  the 
chorionic  epithehum,  or  in  the  stroma  of  the  villi.  Caseation 
is  frequently  found  in  these  deposits,  and  in  cases  of  acute 
maternal  tubercle,  miliary  deposits  may  be  widespread  in  the 
foetal  portion  of  the  placenta.  It  appears  that  there  is  not 
much  probability  of  placental  infection  except  in  advanced 
cases. 

Solid  Tumours  of  the  Placenta  are  extremely  rare,  the 
greater  number  of  those  described  being  myxo-fibromata. 

Hcemorrhage  and  (Edema  also  occur  in  the  j)lacenta.  We 
know  little  of  the  causation  of  the  former  ;  the  latter  is 
always  associated  with  general  oedema  of  the  foetus — one  of 
the  rarest  varieties  of  intra-uterine  disease. 

Placental  Syphilis. — In  1873  Frankel  endeavoured  to 
prove  that  definite  sjqDhiMtic  lesions  occurred  in  the  placenta  ; 
that  the  disease  appeared  in  the  chorionic  vilh  when  the 
father  was  infected,  and  in  the  decidua  when  the  mother  was 
infected.     Syphilitic  villi  he  described  as  of  unusually  large 


PLACENTAL  SYPHILIS  167 

size  from  proliferation  of  the  connective-tissue  stroma,  with 
obliterated  vessels,  and  extensive  fatty  degeneration  of  all 
the  tissues.  The  decidua  he  described  as  thickened  from 
hyperplasia.  His  conclusions  have  been  traversed  by  many 
observers,  and  have  never  been  satisfactorily  confirmed. 

The  question  has  entered  upon  an  entirely  different  phase 
since  the  discovery  of  the  specific  organism  of  syphilis  by 
Shaudinn — the  spirochefa  pallida.  The  presence  of  this 
organism  must  now  be  regarded  as  conclusive  proof  of  the 
disease,  and  as  it  has  been  demonstrated  in  the  placental 
tissues  by  numerous  observers,  the  occurrence  of  syphilitic 
disease  of  the  placenta  is  unquestioned.  The  organism  is 
found  mostly  in  the  foetal  portion  of  the  placenta,  and  is 
distributed  especially  around  the  vessels  running  in  the 
stroma  of  the  villi ;  this  corresponds  with  the  position  in 
which  the  organism  is  found  in  the  case  of  chancres.  When 
present  in  the  placenta  it  can  also  be  readily  demonstrated 
in  the  foetal  viscera,  especially  the  liver. 

Placentae  infected  with  sjrphilis  are  usually  abnormally 
large  and  heavy  ;  the  latter  point  is  of  considerable  practical 
importance,  for  the  great  majority  of  placentae  which  exceed 
the  normal  limits  of  weight  are  syphilitic.  In  appearance 
the  placental  tissue  is  pale,  the  cotyledons  are  voluminous, 
and  the  sulci  between  them  abnormally  deep.  Microscopic- 
ally the  only  definite  change  observed  in  most  instances  is 
that  the  villi  are  abnormally  large,  the  increase  being  due  to 
excess  of  the  connective-tissue  stroma,  which,  however,  is 
not  otherwise  abnormal.  In  this  respect  the  views  of  Frankel 
have  therefore  been  confirmed. 

Abnormal  Conditions  of  the  Foetus. — The  foetus  may  be 
the  subject  of  many  abnormal  conditions,  arising  from 
disease  or  from  errors  of  development.  In  a  certain  number 
of  instances  disease  is  transmitted  from  one  or  other  parent, 
usually  the  mother  ;  in  others  disease  arises  spontaneously 
in  intra-uterine  life.  Very  few  of  these  abnormal  conditions 
are  of  clinical  importance.  A  certain  number  of  develop- 
mental errors,  however,  give  rise  to  difficulty  in  labour,  and 
will  be  referred  to  again  in  that  connection  ;  among  these 
may  be  mentioned  double  monsters,  hydrocephalus,  ascites, 
abdominal  tumours  (usually  cystic),  and  general  dropsy. 
Abnormalities  of  development  do  not,  as  a  rule,  influence 


168  ABNORMAL  PREGNANCY 

the  course  of  pregnancy.  The  foUowmg  microbial  diseases 
have  been  shown  to  be  capable  of  transmission  from  the 
mother  to  the  foetus  :  enteric  fever,  cholera,  yellow  fever, 
cerebrospinal  meningitis,  pertussis,  variola,  scarlatina, 
malaria,  morbilli,  erysipelas,  and  syphilis  (Ballantyne)  ;  the 
appearances  characteristic  of  these  diseases  may  be  present 
at  birth,  or  may  arise  after  delivery  if  the  child  survives. 
Further,  in  the  case  of  tubercle,  aiithrax,  erysipelas,  sepsis, 
and  diphtheria,  the  specific  organism  has  been  found  in  the 
fcetal  tissues,  but  not  the  local  lesions  characteristic  of  these 
diseases  in  the  adult  ;  strictly  spealdng,  the  last-named 
diseases  are  therefore  not  transmitted,  the  cause  of  the  death 
of  the  foetus  under  such  circumstances  being  j^robably 
septicaemia.  Syphilis  may  be  transmitted  from  either 
parent  ;  usually,  however,  it  is  paternal  in  origin.  The 
following  are  the  chief  signs  of  foetal  sj^hilis  as  seen  in  a 
foetus  which  has  perished  from  this  disease  in  utero  :  a 
bullous  eruption  (pemphigus),  seen  especially  upon  the  palms 
and  soles  ;  gummata  in  the  hver  and  spleen  ;  and  in  the  long 
bones  hyperplasia  of  the  cartilaginous  elements  along  the 
line  of  junction  of  the  shaft  with  the  epijDhj^sis — so-called 
syphilitic  epiphysitis. 

EXTRA-UTERINE    (ECTOPIC)    GESTATION 

It  is  now  well  established  that  a  fertihsed  ovum  may 
become  implanted  not  only  in  the  uterus,  but  in  the  Fallopian 
tube  or  in  the  ovary  ;  in  the  two  last-named  positions  the 
pregnancy  is  called  extra-uterine  or  ectopic. 

The  possibility  of  the  implantation  of  a  fertihsed  ovum 
upon  the  peritoneum — primary  peritoneal  p)regnancy — has 
been  much  discussed,  but  until  the  last  year  or  two  it  camiot 
be  said  to  have  been  satisfactorily  demonstrated.  Blair  Bell 
now  claims  to  have  shown  that  it  may  occur  in  rodents,  and 
consequently  its  occurrence  in  the  human  species  cannot  be 
regarded  as  impossible.  Further,  a  case  has  recently  been 
recorded  by  Grone  (Sweden)  which  he  asserts  to  be  one  of 
primary  peritoneal  pregnancy,  the  ovum  having  been 
implanted  upon  the  peritoneum  immediately  behind  the 
right  romid  ligament.  The  case  was  submitted  to  operation, 
and  as  the  patient  recovered  a  detailed  histological  examina- 


OVARIAN   PREGNANCY  169 

tion  of  the  uterus  and  Fallopian  tubes  was  not  made.  While 
there  can  be  no  inherent  impossibility  about  the  occurrence 
of  primary  peritoneal  pregnancy,  its  actual  demonstration  is 
beset  with  great  difficulties,  and  there  can  be  no  question 
that  if  it  occurs  at  all  in  women  it  is  very  much  rarer  than 
the  other  two  varieties  of  ectopic  pregnancy. 

OVARIAN    PREGNANCY 

It  is  only  within  recent  years  that  the  occurrence  of 
ovarian  pregnancy  has  been  satisfactorily  proved,  but  the 
number  of  cases  which  can  be  accepted  as  reliable  instances 
of  the  condition  is  now  fairly  large.  There  can  be  no  doubt 
that  it  is  very  much  less  frequent  than  tubal  pregnancy.  In 
most  cases  the  site  of  implantation  appears  to  have  been  a 
Graafian  follicle,  which  may  be  entered  by  spermatozoa 
through  the  site  of  rupture,  or  possibly  by  direct  penetration 
of  the  wall.  It  is,  however,  possible  that  the  ovum  may 
be  impregnated  when  lying  upon  the  surface  of  the  ovary 
after  its  discharge  from  the  follicle,  and  may  afterwards 
excavate  a  bed  for  itself  in  the  ovarian  tissues  by  its  remark- 
able powers  of  erosion.  Generally,  however,  the  sperma- 
tozoa enter  a  Graafian  follicle,  and  fertilise  an  ovum  therein 
which  has  not  been  discharged  along  with  the  fluid  contents 
of  the  follicle.  In  the  cells  which  line  the  follicle  the  ovum 
finds  its  nidus,  and  the  early  stages  of  development  pursue 
the  usual  course.  Fig.  72  shows  that  the  gestation  sac,  or 
maternal  covering  of  the  ovum,  is  very  thin,  and  consists 
simply  of  thin  layers  of  ovarian  tissue  in  which  some  of  the 
villi  are  imbedded  ;  the  base  of  the  ovum  rests  upon  the 
main  portion  of  the  ovary.  There  is  no  decidual  membrane 
formed  in  ovarian  pregnancy,  although  certain  large  cells  have 
been  found  by  some  observers  and  described  as  decidual. 

The  great  majority  of  cases  of  ovarian  pregnancy  have 
terminated  by  rupture  at  an  early  period  of  gestation. 
Some,  however,  have  progressed  up  to  or  beyond  the  mid- 
term. An  interesting  example  has  been  recorded  by  McCann 
in  which  pregnancy  continued  for  five  and  a-half  months, 
the  sac  being  apparently  on  the  point  of  rupture  when  the 
operation  was  performed.  In  this  case,  the  gestation  was 
situated  in  the  functionally  active  part  of  an  ovary,  which 


170 


ABNORMAL  PREGNANCY 


was  already  the  seat  of  a  cystic  tumoiu'.  A  considerable 
number  of  cases  of  reputed  ovarian  pregnancy  at  term  have 
been  recorded,  but  in  most  instances  the  evidence  of  their 
exact  nature  is  inconclusive. 

Ovarian  pregnancy  cannot  be  distinguished  by  clinical 
methods  from  tubal  pregnancy  ;  questions  of  diagnosis  and 
treatment  are  therefore  identical  with,  those  of  the  latter 


Masses  of 
blood- clot 


Chorio- 

deciduaJ 

pace 


Gra.a,fian. 
follicle 


Ovarian  tissue 

Fig.  72. — Ovarian  Pregnancy  (Van  Tusseiibrock).  The  Ovum  has 
developed  in  a  Gfraafian  Follicle  ;  Eupture  has  occurred  on  the 
free  surface  of  the  G-estation-Sac. 


condition.  The  anatomical  diagnosis  of  an  ovarian  preg- 
nancy is  to  be  made  chiefly  by  careful  attention  to  its 
relations  171  situ,  which  must  be  those  of  the  normal  ovary. 
Fm'ther,  ovarian  tissue  must  be  recognisable  on  microscopic 
examination  in  several  parts  of  the^  gestation  sac,  showing 
that  the  oYary  has  been  expanded  by  its  growth.  The 
histological  elements  which  are  characteristic  of  ovarian 
tissue,  are  Graafian  follicles,  corpora  lutea,  and  in  the 
absence  of  definite  yellow  bodies,  clusters  of   lutein  cells. 


TUBAL  PREGNANCY  171 

Its  differential  diagnosis  by  clinical  methods  from  tubal 
pregnancy  is  impracticable  in  the  present  state  of  om* 
knowledge,  careful  examination  of  the  complete  specimen, 
after  removal,  being  required  to  determine  its  true  nature. 

TUBAL   PREGNANCY 

The  lodgment  of  a  fertilised  ovum  in  the  Fallopian  tube 
is  not  uncommon.  The  causes  of  the  arrest  of  the  ovum  in 
the  tube  on  its  journey  to  the  uterus  are  probably  not 
pathological,  most  of  the  older  explanations  having  been 
disproved  or  abandoned  from  lack  of  supporting  evidence. 
It  is  known,  however,  that  diverticula  of  the  tubal  canal  are 
sometimes  found  running  up  into  the  fibro-muscular  wall  of 
the  tube  ;  it  is  possible  therefore,  that  an  ovum,  either  before 
or  after  being  fertihsed,  may  wander  into  one  of  these 
impasses  and,  being  detained  there,  may  become  engrafted 
upon  the  mucous  membrane,  which  has  the  same  structure 
as  that  of  the  tube  proper.  And  further,  the  anatomical 
arrangement  of  the  tubal  mucosa  is  such  that  the  ovum  may 
readily  become  detained  among  the  complex  ramifications 
of  the  tubal  plicse  in  the  outer  portion  of  the  canal.  The 
view  that  arrest  of  the  ovum  in  the  tube  may  be  due  to  such 
morbid  conditions  as  salpingitis,  or  partial  occlusion  of  the 
tubal  lumen  by  adhesions,  has  not  received  support  from 
morbid  anatomy,  and  must  be  abandoned.  Age  and  social 
condition  do  not  influence  its  occurrence  ;  it  may  be  met 
with  in  a  first  or  in  any  subsequent  pregnancy,  and  in  the 
latter  case  it  may  follow  normal  gestation  after  an  interval 
varying  from  a  few  months  to  many  years.  Tubal  pregnancy 
is  in  all  probability  to  be  regarded  as  an  accidental  occur- 
rence ;  it  is  a  morbid  condition  only  in  the  sense  of  involving 
both  the  mother  and  the  ovum  in  serious  risks.  Consequently 
gravid  tubes  are  usually  healthy  at  the  time  of  the  occur- 
rence of  gestation  (Fig.  77)  ;  in  some  cases,  however,  evi- 
dences of  chronic  salpingitis  are  found,  showing  that  this 
condition  sometimes  precedes  the  gestation  (Fig.  76). 

Anatomy. — Tubal  pregnancy  gives  rise  to  a  series  of 
well-marked  changes  in  the  uterus,  and  in  the  affected 
Fallopian  tube  ;  the  former  are  uniform  and  constant,  the 
latter  vary  with   the  location   of   the   ovum.     The  uterus 


172 


ABNORMAL  PREGNANCY 


always  shows  a  certain  amount  of  enlargement,  accom- 
panied with  softening  of  its  walls  and  softening  of  the  cervix  ; 
both  are  recognisable   clinically,   although  the  softening  of 


Fig.  TS.^Section  tlirougli  a  Gravid  Fallopian  Tube,  illustrating  tte 
formation  of  a  Tubal  Mole  ( Whitridge  Williams).  V,  Villi  whicb 
have  penetrated  deeply  into  the  wall  of  the  tube,  probably 
indicating  the  original  implantation  site;  b.c.  Blood-clot  con- 
taining cboiionic  villi  seen  in  section  :  in  the  centre  of  the  mass 
is  an  irregular  space  representing  the  amniotic  sac. 

the  lips  of  the  external  os  is  not  so  well  marked  as  in  uterine 
pregnancy.  The  size  of  the  uterus  seldom  exceeds  that  of 
two  and  a-half  months  gestation.  The  endometrium  is 
completely    converted    into    a    decidual    membrane    indis- 


TUBAL   PREGNANCY  173 

tinguishable  from  the  decidua  vera  of  normal  uterine  preg- 
nancy. This  change  has  been  spoken  of  by  Webster  as  the 
'  decidual  reaction  '  of  the  uterus.  In  the  affected  tube  the 
changes  are  mainly  confined  to  the  neighbourhood  of  the 
ovum,  distant  parts  showing  practically  no  changes  recog- 
nisable with  the  naked  eye.  No  true  formation  of  a  decidua 
occurs  in  the  tube,  although  it  has  been  demonstrated  that 
clusters  of  large  '  decidual  '  cells  may  be  found  here  and 
there  in  the  mucous  membrane  of  both  the  affected  and  the 
unaffected  tube.  The  portion  of  the  tube  which  encloses 
the  ovum  is  usually  called  the  gestation-sac. 

The  fertilised  ovum  lodges  most  frequently  in  the  ampulla 
of  the  tube,  more  rarely  in  the  isthmus,  and  least  frequently 
of  all  in  the  interstitial  portion.  It  has  been  clearly  shown 
that,  when  lodged  in  the  tube,  the  fertilised  ovum  buries 
itself  in  the  maternal  tissues  very  much  in  the  same  manner 
as  in  uterine  pregnancy.  The  mucous  membrane  under- 
goes no  preparatory  thickening  as  does  the  endometrium  ; 
penetration  of  the  tissues  is  easy,  and  there  appears  to  be 
no  doubt  that  the  ovum  actually  reaches  the  muscular  coat 
and  becomes  completely  imbedded  in  it.  The  ovum  thus 
develops,  for  a  time  at  any  rate,  in  a  cavity  hollowed  out 
of  the  substance  of  the  tube-wall  and  practically  shut  off 
from  the  tube-lumen.  This  arrangement  compensates,  to 
some  extent,  for  the  absence  of  a  complete  decidual  invest- 
ment, and  renders  the  early  lodgment  of  the  ovum  more 
secure.  The  formation  of  the  embryo  and  of  the  embryonic 
coverings  proceeds  in  the  same  manner  as  in  uterine  preg- 
nancy. At  the  site  of  the  growing  ovum  the  tube  undergoes 
rapid  distension  and  assumes  a  somewhat  oval  form.  The 
wall  of  the  distended  portion  becomes  considerably  thinned  ; 
this  thinning  is  due  in  part  to  the  absence  of  compensatory 
muscular  hypertrophy,  such  as  takes  place  in  the  gravid 
uterus,  and  in  part  to  the  eroding  action  of  the  chorion, 
which  penetrates  the  tissues,  and  still  further  thins  the  wall. 
When  the  ovum  lodges  in  the  ampullary  portion  the  ab- 
dominal ostium  almost  invariably  becomes  occluded  before 
the  end  of  the  second  month  (eighth  week)  ;  when  the  ovum 
lies  in  the  isthmus  or  the  interstitial  portion  the  abdominal 
ostium  does  not  close  (Fig.  77).  The  condition  of  the  ostium, 
as  will  appear  later,  has  an  important  clinical  bearing.     A, 


174  ABNORMAL   PREGNANCY 

gravid  tube  is  usually  found,  on  opening  the  abdomen,  to 
have  contracted  adhesions  to  surrounding  structures  ;  and 
at  spots  where  the  penetrating  vilh  have  reached,  or  nearly 
reached,  the  peritoneal  coat,  thick  layers  of  lymph  become 
deposited,  the  effect  of  which  is  to  strengthen  the  weak  spot. 

Erom  this  account  it  is  obvious  that  the  abihty  of  the 
Fallopian  tube  to  continue  to  accommodate  the  growing 
ovum  is  by  no  means  certain  ;  as  a  matter  of  fact  it  fails  to 
do  so  except  in  extremely  rare  instances.  It  is,  however, 
beheved  that  genuine  cases  are  on  record  of  gestation  con- 
tinuing to  term,  or  nearly  to  term,  m  an  miruptured  Fallo- 
pian tube.  Failing  this  event,  either  the  ovum  is  destroyed, 
or  it  escapes  from  its  cramped  surroundings  and  pursues  its 
development  under  more  favourable  conditions.  The  ovum 
may  be  destroyed  in  situ  by  haemorrhage  which  converts  it 
into  a  tubal  mole  ;  or  it  may  be  detached  from  its  base  and 
expelled  either  through  the  patent  abdominal  ostium  {tubal 
abortion),  or  through  a  rent  m  the  wall  of  the  tube  {tubal 
rupture).  In  some  instances  rupture  occurs  without  causing 
complete  detachment  of  the  ovum  ;  its  existence  is  not  then 
necessarily  termmated,  for  development  may  proceed  in  the 
freer  space  thus  gained  for  it. 

The  Tubal  Mole. — The  mode  of  formation  of  a  tubal  mole 
is  weU  shown  in  Fig.  73,  which  represents  a  transverse  section 
through  a  gravid  Fallopian  tube  at  the  site  of  implantation 
of  the  ovum.  The  lumen  of  the  tube  is  occupied  by  an  oval 
mass  of  blood-clot  detached  completely  from  the  wall  ;  a 
cavity  of  irregular  shape,  representing  the  amniotic  sac,  is 
seen,  placed  somewhat  excentrically  in  the  midst  of  the 
blood-clot.  The  effect  of  the  haemorrhage  has  clearly  been 
to  break  up  the  chorion,  which  at  this  early  period  is  covered 
in  all  parts  with  villi  ;  many  detached  vilh  are  seen  in 
section  in  the  blood-clot  surroimduig  the  ovum  ;  a  few  are 
seen  still  retaining  their  attachment  to  the  ovum,  others  are 
seen  to  be  bmied  in  the  tube  waU  and  to  be  broken  off 
entirely  from  the  ovum.  There  is  no  appreciable  thinning  of 
the  wall  of  the  tube  except  at  the  right  of  the  figure,  where 
chorionic  villi  can  be  seen  to  have  penetrated  nearly  as  far 
as  the  peritoneal  investment,  thus  breaking  up  the  muscular 
waU  of  the  tube.  This  spot  probabty  represents  the  pit  in 
which  the  ovum  was  originally  imbedded.     Remains  of  the 


TUBAL   PREGNANCY 


175 


branching  plicae  of  the  tubal  muscosa  are  also  seen  flattened 
out  against  the  tube  wall,  which  indicate  that  the  ovum  has 
lodged  in  the  ampullary  portion  of  the  tube.  In  Fig.  74 
are  seen  the  naked-eye  appearances  of  a  tubal  mole  in  situ 


^<^ty 


Fig.  74. — Tubal  Mole  in  situ,  Laid  Open  by  Longitudinal  Incision  of 
the  Tube  (Charing  Cross  Hospital  Museum).  The  mole  occupies 
the  inner  half  of  the  ampullary  portion  of  the  tube.  The 
abdominal  ostium  is  patent. 


laid  open  by  longitudinal  section  ;  the  tube  was  removed  on 
account  of  haemorrhage  through  the  unsealed  abdominal 
ostium. 

The  statement  is  made  by  Bland-Sutton  that  '  a  tubal 
mole  is  due  to  blood  extra vasated  from  the  circulation  of  the 
embryo.'     This  opinion  rests  solely  upon  the  observation  by 


176 


ABNORMAL   PREGNANCY 


this  author  of  the  occurrence  in  the  tubal  mole  of  nucleated 
red  blood-corpuscles  such  as  are  found  in  the  blood  of  the 
embryo,  but  not  in  that  of  the  adult.  In  reality  all  that  this 
observation  proves  is  that  there  is  in  the  mole  an  admixture 
of  embryonic  blood  ;    but  it  cannot  be  supposed  that  tubal 


Fig.  75. —  Chorionic  Yilli  from  a  Tubal  Mole.  The  large  imbedded 
villus  is  seen  to  have  lost  its  epithelial  covering  ;  its  stroma 
contains  very  few  nuclei.  The  free  villi  have  preserved  their 
epithelium,  which  consists  of  a  double  row  of  cells.  Syncytial 
buds  in  section  are  seen  in  the  upper  part  of  the  figure. 

moles,  which  are  much  larger  and  heavier  than  the  embryo, 
can  be  formed  by  extravasation  of  embryonic  blood  alone. 
There  is  no  doubt  that  they  consist  almost  entirely  of 
maternal  blood,  which  has  been  extravasated  from  the  tube 
wall  among  the  villi. 

In  tubal  pregnancy  the  frequency  with  which  moles  occur 


TUBAL  PREGNANCY 


177 


is  far  greater  than  in  the  case  of  uterine  pregnancy,  probably 
on  account  of  the  greater  insecurity  of  the  ovuhne  attach- 
ments in  the  former.  The  formation  of  a  mole  is  frequently 
accompanied  by  more  or  less  haemorrhage  through  the 
unsealed  abdominal  ostium.  The  ovum  is  of  course  de- 
stroyed by  this  process  ;  small  moles  may,  perhaps,  be 
retained  in  the  tube  and  gradually  disposed  of  by  absorption  ; 
larger  moles  are  usually  expelled  by  tubal  rupture  or  abor- 
tion.    Suppuration  of  a  mole  retained  in  the  tube  probably 


Fig.  76. — Tubal  Pregnancy  terminating  in  Abortion.  The  tubal 
mole  is  seen  partly  extruded  through  the  abdominal  ostium. 
The  tube  is  convoluted  and  its  walls  thickened  from  chronic 
salpingitis ;  its  lumen  is  dilated  and  full  of  blood. 


only  occurs  as  the  result  of  some  form  of  infection,  such  as 
sepsis,  gonorrhoea,  or  bowel-infection. 

In  operating  on  cases  of  tubal  gestation  a  mole  is  fre- 
quently found  among  the  blood  effused  into  the  peritoneal 
cavity  by  rupture  or  abortion  ;  it  exactly  resembles  a  lump 
of  blood-clot,  and  may  remain  unnoticed  unless  carefully 
looked  for.  Small  moles  are  nearly  globular  (Fig.  77)  ;  larger 
ones  are  oval  in  shape,  heavier  and  firmer  than  simple 
clotted  blood  (Fig.  74)  ;  they  often  show  remains  of  the 
amniotic  sac  on  section,  and  on  microscopic  examination, 
E.M.  12 


178  ABNORMAL   PREGNANCY 

after  suitable  hardening,  are  found  to  contain  chorionic  vilH 
imbedded  in  clotted  blood. 

The  recognition  of  chorionic  vilh  under  these  conditions 
is  a  matter  of  some  clinical  importance.  As  shown  in  Fig.  75, 
some  are  free,  others  imbedded  in  the  blood-clot.  The  former 
are  covered  by  epithelium,  definitely  recognisable  as  that  of 
the  chorion,  since  it  is  composed  of  two  layers — the  outer 
layer  consisting  of  irregularly  nucleated  plasmodium  (the 
sync3i:ium),  the  inner  layer  consisting  of  a  single  row  of  low 
columnar  cells  (Langhans'  layer).  The  latter  have  almost 
completely  lost  their  epithehum,  while  the  stroma  of  all  the 
vilh  has  undergone  considerable  degeneration  and  appears 
structureless.  The  epithehum  retains  its  vitahty  for  a  longer 
period  after  the  destruction  of  the  ovum  than  the  stroma  ; 
this  difference  is  due  to  the  fact  that  the  former  is  normally 
nourished  directly  by  the  maternal  blood  ^^ith  which  it  is 
always  in  contact,  while  the  latter  is  normally  nourished  by 
the  blood  in  the  foetal  capillaries.  The  epithelium  can  there- 
fore draw  nourishment  from  the  efifused  blood  in  a  mole,  and 
thus  siu'vive,  while  the  stroma,  being  suddenly  cut  off  from 
its  source  of  nutrition,  perishes  with  the  embryo.  Omng  to 
survival  of  the  epithehum,  viUi  can  be  recognised  in  a  mole 
many  weeks  after  its  formation.  Around  the  vilh  is  seen 
blood-clot,  in  varying  degrees  of  contraction — i.e.,  with  a 
variable  amount  of  fibrinous  network.  Sometimes  quite 
fresh-looking  viUi  may  be  found  in  a  recent  tubal  mole. 

Tubal  abortion  occurs  frequently  m  ampullary  pregnancy 
while  the  abdominal  ostium  remains  patent — i.e.,  during  the 
first  two  months  of  gestation  ;  it  is  believed  that  it  occurs 
almost  as  commonlj^  as  rupture  in  this  variety  of  tubal 
pregnancy.  In  the  isthmial  and  interstitial  varieties,  how- 
ever, rupture  is  much  more  frequent  than  abortion  ;  in  the 
latter  variety  tubal  abortion  consists  in  the  discharge  of  the 
ovum  through  the  uterine  ostium  into  the  uterine  cavity. 
An  aborted  tubal  ovum,  as  a  rule,  has  been  previously  con- 
verted into  a  mole,  but  this  is  not  always  the  case.  The 
first  step  in  the  process  of  tubal  abortion  is  the  separation 
of  the  ovum  from  its  attachments.  We  have  seen  that  as 
a  rule  the  ovum  develops  withui  the  tube  wall,  not  in  the 
lumen  of  the  canal.  At  the  site  of  implantation  the  lumen 
is  distorted  and  compressed  by  the  pressure  of  the  growing 


TUBAL   PREGNANCY 


179 


ovum.  At  some  point  the  tubal  investment  gives  way  and 
the  gestation  sac  ruptures  into  the  lumen  of  the  tube  ;  this 
forms  the  first  step  in  the  occurrence  of  a  tubal  abortion. 
Berkeley  and  Bonney  described  this  process  as  '  intra-tubal 
rupture  '  to  distinguish  it  from  '  tubal  rupture '  in  which 
the  sac  opens  into  the  peritoneum  or  the  broad  ligament 
{vide  infra). 

The  actual  process  of  abortion  is  seen  in  Fig.  76,  which 
shows  that  the  mole  has  been  partly  expelled  through  the 
dilated  abdominal  ostium.  The  main  factor  in  its  produc- 
tion is  undoubtedly  muscular  contraction  of  the  unaffected 


Abdominal 
o-stiu.-im 


Mole 


Cut  end   of  tiibe 


Ovary  -vrith.  ruptiired  cyst 


Fig.  77. — Tubal  Pregnancj^  of  Four  to  Five  Weeks'  Duration. 
Rupture  has  occurred  in  ttie  isthmial  portion  of  the  tube  and  a 
small  mole  has  been  extruded.  The  abdominal  ostium  is  patent, 
and  the  ampullary  portion  shows  little  alteration. 

portions  of  the  tube  ;  the  process  constitutes  a  miniature 
labour,  consisting  of  a  stage  of  dilatation  followed  by  a  stage 
of  expulsion,  which  again  is  succeeded  by  a  stage  of  retraction. 
The  developmental  unity  of  the  uterus  and  Fallopian  tubes 
no  doubt  accounts  for  this  physiological  analogy.  The  con- 
tractions are  perhaps  reflexly  excited  by  haemorrhage, 
causing  sudden  distension  of  the  tube.  The  expulsion  of  the 
ovum  may  be  complete  or  incomplete  ;  in  the  latter  the 
ovum  is  detained  in  the  insufficiently  dilated  abdominal 
ostium,  or  a  portion  of  it  may  remain  attached  to  the  original 
implantation  site  of  the  ovum,  the  bulk  of  which  has  been 
expelled.     Here  again  the  analogy  with  uterine  abortion  will 

12—2 


180 


ABNORMAL  PREGNANCY 


be  obvious.  Tubal  abortion  may  be  attended  by  severe 
internal  bleeding,  equal  in  severity  to  that  caused  by  rupture  ; 
its  result  as  regards  the  ovum  is  invariably  to  destroy  it. 
After  the  expulsion  of  the  ovum  the  tube  usually  remains 
considerably  distended  with  blood  (Fig.  76),  but  it  is  believed 
that  it  may  rapidly  retract  and  resume  its  normal  shape  and 
cahbre,  leaving  no  trace  to  the  naked  eye  of  having  been 

recently  gravid.  It  is 
Amnion  intact  impossible  to  distinguish 
tatolm^toiSi^  tubal  abortion  from  tubal 
^^^^  rupture  by  clinical  diag- 

_  nosis. 

^ation.&ac    kfl  ^  ^  Tubal    Rupture.  —  In 

ruptured        pL,(^.     vj     g|  whatever  part  of  the  Fal- 

-^vA-r-^v  x^^>;>'     fef  lopian  tube  the  fertilised 

ovum  may  be  lodged,  there 
is  a  tendency  to  the  occur- 
rence of  spontaneous  rup- 
ture. In  the  isthmial  and 
interstitial  varieties  rup- 
^^  .-"-==r^--'.-f^P  ture  is  apt  to  occur  earlier 

than    in    the     ampullary 
variety,  owing  to  the  fact 

•'^\^'i Cp/y  th^t   t^®  latter  is    larger 

r//  and  more  distensible  than 

|^^j'l'j||[j  either  of  the  former.    Be- 

tween the  eighth  and  tenth 
Fig.  78.— Intra -Peritoneal  Eupture  week  is  the  commonest 
of  the  Tube  (diagrammatic;  after  ,•  n  ^,,„w-„^^  ..„  ^^^^^ 
Giles).  The  chorion  has  been  torn,  ^^^^  ^^^  rupture  TO  OCCUr, 
but  the  amnion  remains  intact,  the  but  it  may  be  earlier  or 
foetus  contained  yithin  it ;  the  j^ter  than  this.  The 
placental  portion  oi  the  chorion  is  . 

uninjured.  The  foetus  may  survive.  conditions  whlch  predis- 
pose to  rupture  have  been 
mentioned — viz.,  thinning  of  the  tube  wall  by  distension  and 
the  eroding  action  of  the  villi.  In  addition,  there  is  probably 
a  determining  cause  in  most  instances,  such  as  a  sudden 
increase  in  size  of  the  ovum  from  haemorrhage,  or  slight 
increase  in  vascular  tension  from  some  muscular  effort  on 
the  part  of  the  patient.  Occasionally  the  eroding  action  of 
the  vilh  alone  will  determine  spontaneous  perforation  of  the 
wall  of  the  tube.     Occlusion  of  the  abdominal  ostium  is  not 


TUBAL   PREGNANCY 


181 


an  essential  factor  in  the  causation  of  rupture,  for  this 
accident  frequently  occurs  without  it,  even  in  the  ampullary 
variety.  Any  part  of  the  wall  of  the  distended  portion  of 
the  tube  may  burst. 

The  results  of  rupture,  in  so  far  as  the  life  of  the  ovum  is 
concerned,  depend  to  a  great  extent  upon  the  position  of  the 
rent.     If  occurring  upon  the  roof  or  sides  of  the  tube,  the 


Ruptured 
chorion 


Raptured  tube 
—        wall 
(gesboytion  stzc> 


Peritoueum.  of 
hcoad  lig-amenfc 


Connective  tissue  of 
Toroad  ligament 


Fig.  "79. — Intra-Peritoneal  Eupture  of  the  Tube  (dia- 
grammatic ;  after  Griles).  The  chorion  and  amnion 
have  both  been  torn,  and  the  foetus  has  escaped 
from  the  gestation  sac  ;  the  placental  portion  of 
the  chorion  is  injured.     The  toetus  will  perish. 


rupture  will  involve  the  peritoneal  covering,  and  the  blood 
effused  will  therefore  be  poured  out  into  the  general  peri- 
toneal cavity,  while  the  mole  may  be  completely  expelled 
through  the  rent  (Fig.  79).  If,  on  the  other  hand,  the  tear 
takes  place  in  the  floor  of  the  tube,  the  peritoneal  coat  may 
escape,  while  the  effused  blood  and  the  discharged  ovum  will 
make  their  way  between  the  layers  of  the  broad  ligament, 
gradually  separating  them  and  burrowing  in  the  connective 


182 


ABNORIMAL   PREGNANCY 


tissue  which  this  hgament  contains  (Figs.  80  and  81).  This 
form  of  rupture  is  very  uncommon  and  occurs  mainly  in 
cases  of  isthmial  pregnancy,  since  the  lower  wall  of  this 
portion  of  the  tube  is  less  completely  invested  by  peritoneum 
than  the  ampulla.  The  former  is  known  as  intra-peritoneal 
rupture,  the  latter  as  intra-ligamentary  or  extra-peritoneal 
rupture.  In  both  varieties  the  ovum  is,  as  a  rule,  destroyed 
by  previous  haemorrhage  and  converted  into  a  mole.     Apart 


Gestation  sac 
anjd  chorion 

niptured 

Peritoneujn  of 
broad  lig-ament 


Amnion  intact 

.and  protruding' 

into  Ijroad  ligament 


Blood  clot 


Fig.  so. — ^Intra-Ligamentary  Eupture  of  the  Tube 
(diagrammatic ;  after  Giles).  The  amnion  and 
tlie  placental  portion  of  the  chorion  are  uninjured. 
The  foetus  may  survive. 


from  heemorrhage,  pregnane}"  almost  invariably  comes  to  an 
end  (a)  if  the  amnion  is  ruptured,  or  (b)  if  the  placental  por- 
tion of  the  chorion  is  lacerated  or  detached  by  the  rupture 
(Figs.  79  and  81).  Occasionallj^,  however,  the  ovum  may 
continue  its  development,  and  in  such  cases  it  is  observed 
that  the  amnion  has  remained  intact,  and  that  the  placental 
chorion  was  so  situated  as  to  escape  injury  from  the  rupture 
(Figs.  78  and  80).  In  intra-peritoneal  rupture  the  placenta 
then  grows  out  of  the  rent  and  becomes  attached  to  the 
neighbouring  peritoneal  surfaces,  while  layers  of  lymph  are 


TUBAL   PREGNANCY 


183 


deposited  upon  the  exposed  amnion  from  the  surrounding 
peritoneum,  forming  a  false  membrane  which  constitutes  a 
secondary  gestation  sac.  This  secondary  sac  becomes 
further  strengthened  by  adhesion  to  the  neighbouring  peri- 
toneal surfaces,  including  omentum,  coils  of  intestine,  and 
the  abdominal  parietes.  The  ovum  is  now  known  as  a 
secondary  abdominal  (intra-peritoneal)  pregnancy.  Precisely 
similar   results    may  follow  extra-peritoneal    rupture,   and 


I  Gestation 
sac, 
amnion  hi 
chorion . 


Blood  dot 
Fig.  81. — Intra-Ligamentary  Rupture  of  the  Tube 
(diagrammatic ;  after  Giles).  The  chorion  and 
amnion  have  both  been  torn,  and  the  placental 
portion  of  the  chorion  is  injured.  The  foetus  will 
})erish.     Bleeding  is  intra-ligamentary. 


for  the  same  reasons  ;  the  condition  is  then  described  as 
secondary  abdominal  (intra-ligamentary)  pregnancy  (Fig.  80). 
Of  intra-ligamentary  pregnancy  two  varieties  are  described. 
In  the  anterior  variety  the  ovum  in  its  growth  raises  the 
anterior  peritoneal  layer  of  the  broad  ligament,  and  strips 
the  peritoneum  from  the  abdominal  wall.  When  fully  de- 
veloped, such  a  gestation  sac  may  be  incised  and  evacuated 
without  entering  the  peritoneal  cavity  at  all.  In  the 
posterior  variety  the  posterior  layer  of  the  broad  ligament 
and  the  floor  of  the  pouch  of  Douglas  are  elevated  by  the 


184  ABNORMAL   PREGNANCY 

growth  of  the  foetus,  and  the  sac  can  then  only  be  reached 
by  a  trans-peritoneal  operation.  Both  intra-peritoneal  and 
intra-ligamentary  pregnancy  may  continue  to  term  ;  the 
patient  then  usually  passes  through  a  '  false  labour,'  and  the 
foetus  perishes.  The  occurrence  of  this  false  labour  is  a 
physiological  point  of  great  interest  and  importance,  but 
we  have  no  information  as  to  its  causation,  or  the  mode  in 
which  it  leads  to  the  death  of  the  foetus.  False  labour  is 
attended  with  severe  abdominal  pain,  which  is  mistaken  by 
the  patient  for  labour,  but  there  is  no  clinical  evidence  that 
uterine  contractions  play  any  part  in  its  production.  Intra- 
ligamentary  pregnancy  may  undergo  secondary  rupture  into 
the  peritoneal  cavity  ;  even  then  the  ovum  is  not  in  all 
cases  destroyed,  but  may  continue  as  an  intra-peritoneal 
pregnancy. 

In  the  intra-peritoneal  form  of  secondary  abdominal 
pregnancy  the  gestation  sac  consists  of  a  membrane  which 
is  largely  inflammatory  in  origin,  and  is  composed  of  layers 
of  lymph  deposited  upon  the  amnion,  in  which  organisation 
has  proceeded  to  a  variable  extent.  This  membrane  becomes 
closely  adherent  internally  to  the  amnion,  externally  to  the 
abdominal  walls,  and  to  the  viscera,  which  structures  support 
it  and  add  to  its  strength.  A  great  deal  of  the  placental 
blood  supply  is  obtained  from  adherent  omentum  and 
mesentery. 

In  the  intra-ligamentary  form  the  gestation  sac  consists 
of  the  tissues  composing  the  broad  ligament,  which  are 
progressively  expanded  as  the  foetus  grows.  This  process 
involves  great  changes  in  the  anatomical  relations  of  the 
parts.  Thus  the  peritoneum  is  raised  from  the  pelvis,  and 
stripped  off  the  anterior  abdominal  wall,  so  that  the  reflection 
which  corresponds  to  the  floor  of  the  utero-vesical  pouch 
may  exceed  the  height  of  the  umbilicus  (anterior  variety), 
or  the  level  of  the  pouch  of  Douglas  is  raised,  and  the 
mesentery  of  the  colon  on  either  side  may  be  opened  up  and 
stretched  over  the  gestation  sac.  An  incidental  result  of 
these  changes  is  that  in  such  cases  the  sac  may  be  opened  by 
an  abdominal  incision  without  traversing  the  peritoneal 
cavity  at  all  (anterior  variety). 

Many  cases  are  on  record,  both  in  ancient  and  in  modern 
times,  in  which  an  extra-uterine  foetus  has  been  retained 


TUBAL   PREGNANCY  185 

within  the  abdominal  cavity  for  many  years  after  its  death. 
In  some  of  these  cases  the  gestation  sac  has  become  infected 
from  the  bowel  or  the  uterus,  and  suppuration  has  occurred, 
resulting  in  the  formation  of  fistulous  communications  with 
the  exterior,  or  with  the  neighbouring  hollow  viscera — large 
intestine,  bladder,  and  vagina.  Through  these  fistulse  foetal 
bones  are  from  time  to  time  discharged.  When,  however, 
the  sac  remains  free  from  infection  the  body  of  the  fcBtus 
shrinks  by  absorption  of  its  fluid  constituents,  and  upon 
the  dried  tissues  lime-salts  become  freely  deposited,  con- 
verting it  into  a  lithopoedion.  In  this  condition  it  may  be 
retained  for  many  years  with  little  disturbance  to  the 
patient. 

Clinical  Features  of  Tubal  Pregnancy 

This  subject  will  be  considered  in  relation  to  three 
stages  :  (a)  before  the  occurrence  of  internal  haemorrhage, 
(6)  after  that  occurrence,  (c)  in  secondary  abdominal  preg- 
nancy. 

(a)  Before  the  Occurrence  of  Internal  Haemorrhage. — 
At  this  time  tubal  pregnancy  gives  rise  to  little  more  local  or 
general  disturbance  than  does  an  early  pregnancy  in  the 
uterus.  An  important  symptom  often  associated  with  this 
phase — namely,  a  brief  period  of  amenorrhoea — is  a  most 
useful  aid  in  diagnosis,  but  it  is  by  no  means  always  present. 
When  a  healthy  adult  woman,  who  is  usually  regular,  goes 
for  two  or  three  weeks  over  the  expected  date  of  her  period, 
there  is  a  strong  presumption  of  pregnancy,  but  at  this  time 
there  may  be  little  to  indicate  whether  pregnancy  is  uterine 
or  extra -uterine.  In  the  latter  case,  however,  amenorrhoea 
is  of  very  brief  duration,  seldom  more  than  seven  or  eight 
weeks  ;  it  then  gives  place  to  haemorrhage.  In  something 
like  30  per  cent,  of  cases  there  is  no  interruption  of  men- 
struation at  all,  and  therefore  while  amenorrhoea  forms  a 
useful  positive  indication,  no  importance  whatever  can  be 
attached  to  its  absence.  Recurrent  attacks  of  abdominal 
pain  on  the  same  side  as  the  gravid  tube  are  often  met  with, 
and  are  probably  due  to  tubal  distension.  As  it  is  quite 
unusual  for  an  extra-uterine  gestation  to  continue  undis- 
turbed beyond  the  end  of  the  second  month,  there  is  no  time 


186 


ABNORMAL   PREGNANCY 


for  the  appearance  of  other  general  symptoms  of  pregnancy. 
But  occasionally  morning  sickness  and  early  breast  changes 
may  be  met  with. 

The  unruptured  gravid  tube  forms  an  elastic  swelling  lying 
as  a  rule  posteriorly  or  postero-laterally  to  the  uterus  (Fig. 


Fig.  82. — Tubal  Abortion  with  Hfematosalpinx  (Bumm).  Tbe  ovum, 
converted  into  a  mole,  has  been  expelled  from  tbe  tube,  which  remains 
distended  with  blood.  The  gravid  tube  occupies  the  left  posterior 
quarter  of  the  pelvis,  and  is  connected  by  a  pedicle  with  the  uterine 


82)  ;  it  may  in  rare  cases  be  found  in  the  utero-vesical  pouch. 
Pulsating  vessels  are  often  to  be  felt  beneath  it.  Its  physical 
characters  do  not  distinguish  it  from  tubal  enlargements  due 
to  other  causes,  and  its  nature  can  only  be  deduced  from  the 
accompanying  symptoms. 

It  appears  certain,  from  clinical  observation,  that  symp- 


TUBAL   PREGNANCY  187 

toms  other  than  those  just  described  do  not  occur  until 
haemorrhage  has  taken  place — either  into  the  tube  itself, 
into  the  peritoneal  cavity,  or  into  the  broad  ligament.  In 
the  majority  of  cases  the  first  sign  of  disturbance  is  the 
occurrence  of  a  little  external  bleeding  from  the  uterus 
(metrorrhagia),  which  may  precede  by  a  few  days  any  of  the 
more  serious  symptoms  which  inevitably  follow.  These 
symptoms,  which  will  be  described  below,  are  commonly 
regarded  as  the  symptoms  of  extra-uterine  gestation,  but 
they  are  in  reality  secondary  symptoms,  inasmuch  as  they 
result  not  directly  from  the  gestation,  but  from  certain 
disturbances  which  either  destroy"  the  ovum  or  greatly 
modify  the  course  of  its  development.  Naturally  the 
secondary  symptoms  are  not  uniform,  for  they  depend 
upon  the  nature  and  extent  of  the  damage  which  has  been 
sustained  by  the  ovum  and  the  tube.  In  any  case  a  marked 
and  rapid  transformation  of  the  clinical  features  takes  place 
as  soon  as  the  normal  course  of  gestation  is  disturbed. 

(6)  After  the  Occurrence  of  Internal  Bleeding. — The 
uterine  haemorrhage  continues  and  is  usually  steady,  not 
irregular,  moderate  in  amount,  and  dark  in  colour.  Separa- 
tion and  discharge  of  the  decidua  may  also  occur,  sometimes 
in  the  form  of  a  complete  cast  of  the  uterus,  more  often  in 
fragments  ;  in  some  cases  the  discharge  of  the  decidua  is  not 
recognised  at  all,  and  it  is  possible  that  it  may  be  cast  off 
gradually  in  the  form  of  debris.  The  characters  of  the 
decidua  are  definite  and  uniform,  and  their  recognition  may 
be  of  considerable  help  in  diagnosis. 

The  decidual  membrane  is  smooth  upon  its  inner  and 
rough  upon  its  outer  surface,  which  is  also  often  beset  with 
small  papillary  elevations.  Microscopically  it  is  seen  to  con- 
sist of  a  superficial  compact  layer  and  a  deep  reticulated  or 
cavernous  layer  (Fig.  83).  The  surface  epithelium  is  almost 
entirely  lost,  and  very  few  glands  are  to  be  found  in  the 
compact  layer,  which  consists  of  closely  packed  masses  of 
oval,  round,  or  polygonal  cells  with  large  globulari  nuclei — 
the  decidual  cells.  Many  large  venous  sinuses  and  numerous 
interstitial  haemorrhages,  sometimes  of  large  size,  are  com- 
monly found  in  this  part  of  the  membrane  after  it  has  been 
shed.  The  deep  layer  contains  many  irregularly  dilated 
glands,  in  most  of  which  the  epithelium  is  fairly  well  pre- 


188 


ABNORMAL  PREGNANCY 


served.  The  presence  of  decidual  cells  in  small  numbers  in 
tissue  passed  from  the  uterus  is  not  of  much  importance,  but 
a  membrane  possessing  the  characters  above  described  is 
distinctive  of  pregnancy.  In  cases  of  uterine  pregnancy 
(abortion)   traces   of   chorionic   epitheUum   will  usually  be 


C^. 


^ 


^V^^ 


'tfe- 


t^t^f^^- 


^^m- 


w  yi 


H 


v^  y 


'^cf:^':-.- 


■Ji?^ 


^SVtr^-'^ 


Fig.  83. — Decidual  Cast  from  a  case  of  Extra-Uterine  Gestation.  A 
large  interstitial  haemoiTliage  is  seen  in  the  centre  of  membrane ; 
to  the  left  are  seen  clusters  of  decidual  cells. 


found  attached  to  the  decidual  membrane,  but  naturally 
this  will  not  be  found  in  extra-uterine  pregnancy. 

The  clinical  results  of  internal  bleeding  in  tubal  preg- 
nancy are  variable  and  mainly  depend  upon  two  factors, 
viz.,  the  amount  and  the  rapidity  of  the  bleeding.  If  the 
haemorrhage  is  rapid  and  the  amount  of  blood  lost  great,  the 
effused  blood  becomes  distributed  over  the  general  peritoneal 
cavity,  and  tends  to  accumulate  in  the  most  dependent  parts, 


TUBAL   PREGNANCY  189 

viz.,  the  pouch  of  Douglas  and  the  renal  pouches  ;  this  is  the 
disuse  type  sometimes  spoken  of  as  '  intra-peritoneal 
flooding.'  If  the  hemorrhage  is  slow  or  the  amount  small, 
the  effused  blood  becomes  quickly  shut  off  from  the  general 
peritoneal  cavity  by  the  formation  of  lymph  around  it  ;  this 
is  the  encysted  type. 

Diffuse  Type  of  Intra-peritoneal  Bleeding. — Occasionally 
a  single  sudden  hsemorrhage  occurs  so  rapid  and  profuse  as 
to  cause  death  in  a  few  hours,  before  surgical  aid  can  be 
obtained.  Blacker  has  recorded  a  case  which  ended  fatally 
in  twenty  minutes.  In  such  a  case  the  hsemorrhage  is 
always  intra-peritoneal,  and  may  be  due  either  to  tubal 
rupture  or  to  tubal  abortion.  More  frequently  diffuse 
hsemorrhage  is  less  severe,  ceases  spontaneously  after  a  time, 
and,  while  imperilling  the  patient's  life,  is  not  necessarily 
fatal.  It  may,  however,  recur  after  an  interval  and  prove 
ultimately  fatal.  The  initial  attack  of  bleeding  may  occur 
without  any  exciting  cause,  when  the  patient  is  at  rest  in 
bed,  or  even  when  asleep  ;  more  often  it  appears  to  have  been 
induced  by  some  slight  muscular  effort,  such  as  that  entailed 
by  ordinary  domestic  work  or  by  the  act  of  defsecation. 

Severe  abdominal  pain,  sudden  in  onset,  situated  in  one 
or  both  iliac  regions,  is  usually  the  first  symptom.  It  is 
often  quickly  followed  by  vomiting,  and  may  lead  to  faint- 
ness  or,  less  often,  to  actual  loss  of  consciousness  from 
syncope.  Upon  these  symptoms  supervene,  in  cases  of 
profuse  bleeding,  the  signs  and  symptoms  of  concealed 
hsemorrhage — pallor,  rapid  and  feeble  pulse,  deep  laboured 
breathing  (air-hunger),  restlessness,  coldness  of  the  extremi- 
ties or  of  the  whole  skin-surface  of  the  body,  sweating, 
depression  of  temperature.  Slight  hsemorrhage  from  the 
uterus  will  also  usually  occur. 

The  presence  of  a  large  amount  of  free  blood  in  the  peri- 
toneal cavity  can  usually  be  detected  by  percussion  ;  when 
the  patient  is  lying  down,  it  gravitates  into  the  flanks,  which 
accordingly  become  dull,  and  the  area  of  dulness  shifts 
slowly  when  the  position  of  the  patient  has  been  altered. 

Gradual  improvement  supervenes,  and  in  two  or  three 
days  the  symptoms  generally  subside.  There  is,  however, 
great  risk  under  these  circumstances  of  renewal  of  the 
bleeding,  which  will  manifest  itself  by  recurrence  of  more  or 


190  ABNORMAL   PREGNANCY 

less  acute  attacks  of  pain  and  of  some  of  the  symptoms  of 
shock.  Even  while  the  patient  is  confined  to  bed  recurrences 
of  bleeding  may  be  met  with,  a  risk  which  is  sufficiently 
explained  by  the  anatomical  points  already  referred  to. 

Wlien  a  diffuse  haemorrhage,  though  severe,  is  not  large 
enough  immediately  to  imperil  life  the  symptoms  resemble 
those  of  the  condition  often  called  '  peritonism,'  and  are 
common,  with  variations,  to  many  circumstances  under 
which  fluid  suddenly  escapes  into  the  peritoneal  cavity. 
These  symptoms  are  acute  abdominal  pain,  at  first  located 
to  one  iliac  region,  but  soon  becoming  general,  with  more  or 
less  profound  shock  ;  the  symptoms  of  shock  differ  from 
those  of  profuse  bleeding  chiefly  in  the  absence  of  restlessness 
and  air-hunger.  The  pain  may  last  for  many  hours,  and 
may  be  accompanied  by  abdominal  distension  and  by 
vomiting,  but  the  latter  is  not  persistent. 

The  diagnosis  of  tubal  pregnancy  under  these  conditions 
is  sometimes  fairly  simple.  When  there  has  been  a  profuse 
loss  of  blood  the  fact  that  internal  bleeding  has  occurred  will 
be  obvious  from  the  signs  abeady  described  ;  a  history  of  a 
recent  short  period  of  amenorrhoea  giving  place  to  shght 
uterine  bleeding,  will  suggest  the  possibility  of  ectopic 
pregnancy.  Pelvic  examination  may  show  softening  of  the 
cervix  and  a  swelling  behind  or  to  one  side  of  the  uterus 
which  represents  the  gravid  tube  (Eig.  82).  These  findings 
together  make  up  a  strong  presumptive  case  for  the  diagnosis 
of  tubal  pregnancy  with  internal  bleeding. 

When  the  loss  of  blood  has  been  less  severe  than  this  the 
symptoms  are  less  characteristic,  and  there  may  be  some 
doubt  whether  haemorrhage,  perforation  of  a  hollow  viscus, 
or  acute  inflammation,  e.g.,  of  the  appendix,  has  occurred. 
The  history  may  be  misleading,  inasmuch  as  early  uterine 
pregnancy  may  be  associated  with  any  of  these  surgical 
disasters  in  women  in  the  fertile  period  of  life.  And  further, 
the  local  conditions  may  be  misleading,  for  cases  have 
occurred  not  infrequentlj^  in  which  a  pelvic  swelling  taken 
for  a  gravid  tube  has  been  revealed  by  operation  as  an 
acutely  inflamed  ovary  or  a  small  ovarian  cyst.  If  the 
condition  of  the  patient  is  not  too  serious  to  allow  of  delay, 
the  further  course  of  the  case  will  often  clear  up  the  diagnosis, 
for  after  internal  haemorrhage  has  ceased  the  general  con- 


TUBAL   PKEGNANCY  191. 

dition  rapidly  improves,  while  with  such  lesions  as  perforative 
peritonitis  the  general  condition  as  rapidly  deteriorates. 

Encysted  Type  of  Intra-peritoneal  Bleeding. — In  this 
form  bleeding  is  more  gradual  than  in  the  diffuse  type,  and 
the  signs  of  internal  haemorrhage  are  usually  inconspicuous. 
Nevertheless  a  certain  amount  of  pallor  and  quickening  of 
the  pulse  are  present  from  the  first,  and  may  become  more 
pronounced  as  the  case  proceeds.  The  two  prominent 
symptoms  constantly  encountered  are  pain  and  uterine 
haemorrhage. 

The  pain  which  is  met  with  is  almost  always  sudden  in 
onset,  and  usually  spontaneous,  although  muscular  effort 
may  appear  to  excite  it  ;  it  is  always  severe,  and  may  be 
intense  ;  beginning  in  one  or  other  iliac  region,  it  soon  affects 
the  whole  abdomen,  but  later  on  may  again  become  localised  ; 
it  is  frequently  attended  with  vomiting  and  other  signs  of 
shock,  sometimes  with  faintness  or  actual  syncope  ;  after 
lasting  acutely  for  several  hours  it  subsides,  and  thereafter 
may  recur  at  varying  intervals  of  a  few  days  or  a  week,  until 
several  attacks  have  been  sustained  ;  sometimes  continuous 
pain  without  exacerbations  follows  the  first  attack. 

The  uterine  haemorrhage  often  begins  before  the  first 
attack  of  pain  ;  it  shows  the  characters  already  mentioned, 
and  may  be  accompanied  by  discharge  of  a  decidual  cast, 
either  complete  or  in  fragments. 

After  a  few  days  an  irregular  elevation  of  the  temperature 
occurs,  as  a  rule,  and  this  symptom  in  association  with  pain 
often  leads  to  the  erroneous  diagnosis  of  an  inflammatory 
lesion.  This  rise  of  temperature  is  due  in  part  to  the  peri- 
tonitic  reaction  which  occurs  around  the  effused  blood,  and 
results  in  its  isolation,  and  in  part  to  the  absorption  of  fibrin 
ferment  or  other  products  from  the  dead  blood. 

The  blood  which  is  slowly  poured  into  the  peritoneal 
cavity  from  the  gravid  tube  tends  to  accumulate  in  the  most 
dependent  part  of  the  peritoneal  cavity— the  pouch  of 
Douglas.  In  some  cases,  probably  when  the  bleeding  is  very 
slow,  the  effused  blood  does  not  reach  the  pouch  of  Douglas 
at  all  ;  it  becomes  rapidly  encysted  by  adhesive  peritonitis 
and  is  detained  in  contact  with  the  bleeding  part,  which  may 
be  the  abdominal  ostium,  or  a  rent  in  some  other  part  of  the 
tube.     An  encysted  collection  of  blood  in  the  pelvic  peri- 


192  ABNORMAL   PREGNANCY 

toneal  cavity  is  called  a  pelvic  hcematocele  ;  when  formed 
around  the  abdominal  ostium  it  is  distinguished  as  peritubal, 
when  formed  upon  a  rupture  in  the  proximal  part  of  the  tube 
it  is  called  paratubal  (Handley).  Around  these  encysted 
collections  of  blood  a  false  capsule  is  rapidly  formed  by  the 
deposition  of  layers  of  lymph  externally,  and  beneath  this 
by  organisation  of  the  superficial  layers  of  the  blood-clot. 
In  this  way  a  membrane  one-eighth  to  one-quarter  of  an 
inch  in  thickness  may  be  formed.  In  those  rare  instances 
where  intra-hgamentary  rupture  occurs,  the  blood  is  slowly 
poured  out  between  the  layers  of  the  broad  ligament,  and 
tliis  condition  is  distinguished  as  a  pelvic  licematoina.  Hsema- 
tocele  of  the  pouch  of  Douglas  is  far  commoner  than  either 
of  the  other  varieties. 

In  some  instances  considerable  intra-tubal  haemorrhage 
may  occur  without  any  escape  of  blood  from  the  tube  taking 
place.  An  acute  attack  of  pain,  or  it  may  be  recurrent 
attacks,  indistinguishable  from  those  just  described,  usually 
accompanies  this  form  of  haemorrhage  also. 

Diagnosis  of  the  Encysted  Type. — From  the  symptoms 
which  have  been  already  described,  a  presumptive  diagnosis 
of  tubal  pregnancy  with  internal  bleeding  can  generally  be 
made.  The  physical  signs  met  with  are  mainly  those  of  a 
pelvic  effusion,  the  nature  of  the  effusion  being  inferred  from 
the  history  and  the  symptoms. 

A  large  pelvic  hcematocele  forms  a  swelling  extending 
upwards  above  the  pubes  (Fig.  84).  The  hypogastric  region 
is  prominent,  and  pressure  causes  considerable  pain.  On 
palpation  a  dome-shaped  swelling,  iU-defined  in  outline  and 
elastic  in  consistence,  can  be  made  out.  Its  position  is 
usually,  but  not  always,  mesial.  On  percussion  the  note  is 
subresonant.  The  surface  of  the  swelling  felt  in  the  hypo- 
gastrium  corresponds  to  the  roof  of  the  haematocele,  which 
is  formed  by  omentum  and  coils  of  intestine  adherent  to  one 
another  and  to  the  mass  of  effused  blood  beneath  them. 

On  vaginal  examination,  it  will  be  found  the  whole  uterus 
including  the  cervix  is  displaced  forwards  and  pressed  close 
up  to  the  back  of  the  symphysis  pubis  ;  sometimes  it  is  some- 
what elevated,  and  may  be  displaced  a  little  to  one  or  other 
side  of  the  middle  line.  Softening  of  the  hps  of  the  os 
externum  may  be  recognisable.     The  rest  of  the  pelvis  is 


TUBAL   PREGNANCY 


193 


occupied  by  the  effusion  which  has  crowded  the  uterus  out  of 
its  normal  position  ;  sometimes  it  depresses  the  floor  of  the 
pouch  of  Douglas  and  causes  bulging  of  the  posterior  fornix. 
The  consistence  of  the  swelling  is  generally  elastic  ;  it  may 
be  almost  doughy  in  parts,  or  on  the  other  hand  areas  which 


Fig.  84. — Pelvic  Heematocele  shown  in  Mesial  Sagittal  Section  (Bumm). 
The  section  shows  the  Heematocele  distec  cling  the  Pouch  of  Douglas 
and  pushing  the  Uterus  forwards.  Attached  to  the  left  wall  of  the 
Hsematocele  is  a  Tubal  Mole. 


feel  firm  and  solid  may  be  encountered.  These  variations 
are  probably  due  to  incomplete  or  irregular  coagulation  of 
blood.  The  pelvic  mass  is  continuous  with  that  felt  above 
the  pubes.  On  rectal  examination  it  may  be  found  to  fill  the 
sacral  hollow  (Fig.  84)  and  compress  the  bowel  ;  thickening 
of  the  utero-sacral  folds  is  also  commonly  felt,  and  probably 
results  from  coagulation  taking  place  upon  their  surfaces, 

E.M.  13 


194  ABNORMAL   PREGNANCY 

Differential  Diagnosis  of  Pelvic  Hcematocele. — In  consider- 
ing this  point  it  must  be  recollected  that  although  the  great 
majority  of  pelvic  hsematoceles  are  due  to  ectopic  pregnancy, 
this  is  not  invariably  the  case.  Thus  Jayle  has  recently 
collected  seventeen  cases  due  to  rupture  of  a  small  blood  cyst 
in  the  ovary,  and  others  have  been  recorded  from  rupture  of 
a  tubo-ovarian  varicocele. 

A  pelvic  hsematocele  must  be  carefully  distinguished  from 
retroversion  of  the  gravid  uterus  ;  the  differential  diagnosis  is 
not  always  easy.  It  is,  however,  of  practical  importance,  for 
if  the  treatment  of  a  retroverted  gravid  uterus  were  applied 
to  a  case  of  pelvic  hsematocele,  disaster  might  foUow  from 
rupture  of  the  hcematocele. 

The  history  usually  presents  weU-defined  differences. 
Thus  retention  and  incontinence  of  urine,  common  in  retro- 
version when  the  uterus  has  grown  large  enough  to  fill  the 
pelvis,  are  exceptional  with  hsematocele.  Bleedmg  from  the 
uterus  may  occur  with  either,  but  the  discharge  of  decidual 
tissue  is  only  met  with  in  extra-uterine  cases.  Attacks  of 
severe  abdominal  pain  strongly  favour  the  diagnosis  of 
hsematocele. 

On  bimanual  examination,  the  bladder  being  empty,  it 
is  necessary,  in  order  to  recognise  that  the  condition  is  a 
pelvic  hsematocele,  to  determine  that  the  body  of  the  uterus 
lies  in  front  of  the  swelling  which  fills  the  pouch  of  Douglas. 
Ansesthesia  may  be  required  to  determine  this  point  satisfac- 
torily. If  the  fundus  cannot  be  felt  in  front,  or  to  one  or 
other  side,  it  may  be  concluded  that  the  swelling  felt  pos- 
teriorly is  the  enlarged  uterine  body.  Two  points  of  minor 
importance  may  assist  the  diagnosis,  viz.,  the  gravid  uterus 
is  of  more  uniform  consistence  than  the  hsematocele,  and 
may  sometimes  be  felt  to  undergo  intermittent  contractions. 

Peri-  and  para-  tubal  hsematoceles  cannot  be  clinically 
distinguished  from  a  hsematosalpinx.  Effusions  of  blood 
into  the  broad  hgament  (hsematoma)  closely  resemble 
inflammatory  effusions  in  the  same  position  (cellulitis),  and 
are  best  distinguished  by  the  clinical  history. 

(c)  Secondary  Abdominal  Pregnancy .^The  clinical  diag- 
nosis of  this  condition  presents  considerable  difficulties,  and 
m  the  great  majority  of  the  recorded  cases  diagnosis  has  not 
been  made  until,  following  upon  the  death  of  the  foetus,  the 


TUBAL   PREGNANCY  195 

gestation  sac  has  become  altered  by  infection  or  by  shrinkage. 
The  history  of  the  pregnancy  presents  abnormal  features, 
such  as  attacks  of  abdominal  pain  in  the  early  months, 
usually  accompanied  by  haemorrhage  ;  but  when  the  ovum 
survives  a  tubal  rupture,  the  amount  of  internal  bleeding 
appears  to  be  inconsiderable,  and  the  accompanying  symp- 
toms less  urgent  than  those  described  above.  In  advanced 
pregnancy  the  local  conditions  may  closely  resemble  those 
of  normal  pregnancy,  the  position  of  the  body  of  the  foetus, 
and  of  the  presenting  part,  showing  little  abnormality. 
Careful  examination  under  anaesthesia  would,  however,  show 
that  the  uterus  was  small,  and  was  displaced  to  some  extent 
by  the  gestation  sac,  while  the  use  of  the  sound  would 
indicate  that  the  uterine  cavity  was  only  slightly  enlarged 
and  empty.  The  differential  diagnosis  of  the  intra-ligamen- 
tary  from  the  intra-peritoneal  variety  presents  even  greater 
difficulties  ;  in  the  latter  the  foetus  usually  lies  above  the 
pelvic  brim  and  is  more  freely  movable  ;  while  in  the  former 
the  head  may  lie  unusually  low  in  the  pelvis  to  one  or  other 
side,  and  the  mobility  of  the  foetus  may  be  unusually  limited. 
The  uterus  would  be  displaced  to  the  side  opposite  to  the 
head.  But  absolute  reliance  cannot  be  placed  upon  these 
points. 

The  foetus  often  perishes  before  full  time  is  reached  ;  it 
may,  however,  survive  until  term  has  been  exceeded.  A 
definite  attack  of  pain  such  as  could  be  called  a  "  false 
labour  "  does  not  in  all  cases  occur  ;  but  when  met  with  it 
is  usually  synchronous  with  the  death  of  the  foetus.  After 
this  occurrence  the  abdominal  enlargement  may  gradually 
decrease  from  absorption  of  fluid  ;  on  the  other  hand  it  may 
rapidly  increase  in  size  either  from  haemorrhage  into  the 
gestation  sac,  or  from  infection  reaching  it  from  the  bowel. 
Infection  is  usually  distinguishable  from  haemorrhage  by 
being  accompanied  by  fever. 

Old  cases  of  secondary  abdominal  pregnancy  in  which 
the  foetus  has  been  retained  for  prolonged  periods  after  its 
death  are  almost  incapable  of  being  clinically  diagnosed.  It 
is  curious  to  note  the  extraordinary  resistance  to  infection 
from  adherent  intestine  which  this  condition  exemplifies. 
Notwithstanding  the  large  mass  of  dead  matter  which  the 
gestation  sac  contains,  and  its  contiguity  to  sources  of  infec- 

13—2 


196  ABNORMAL   PREGNANCY 

tion,  the  processes  of  dry  gangrene  (mummification)  and 
subsequent  incrustation  with  hme  salts  may  proceed  without 
apparent  interruption,  and  the  presence  of  the  large  foreign 
body  thus  built  up  may  be  tolerated  for  many  years  with 
little  apparent  inconvenience.  Many  instances  are  on 
record  of  a  hthojDeedion  being  found  in  the  body  of  a  woman 
who  died  of  some  independent  malady,  at  an  advanced  age. 
Thus  Kuchenmeister  has  recorded  the  case  of  a  woman  who 
died  at  the  age  of  eighty-seven,  and  in  whose  body  a  Htho- 
psedion  was  found  which,  it  was  estimated,  had  been  retained 
for  a  period  of  fifty-seven  years.  In  some  cases,  however, 
the  hthopsedion  has  proved  to  be  the  direct  cause  of  death 
from  intestinal  obstruction. 

Treatment  of  Extra-Uterine  Pregnancy 

This  subject  must  be  considered  in  relation  to  the  various 
clinical  phases  just  described. 

(1)  In  the  case  of  an  unruptured  extra-uterine  gestation, 
the  gravid  tube  or  ovary  should  be  removed  without  delay 
by  abdominal  section.  The  great  probability  that  internal 
haemorrhage  will  occur,  with  its  serious  risks  to  life,  neces- 
sitates this  preventive  operation  being  performed  in  all  cases. 
The  operation  required  is,  in  the  case  of  tubal  pregnancy,  the 
removal  of  the  gravid  tube  ;  the  corresponding  ovary  is,  as 
a  rule,  healthy,  and  should  not  be  removed.  The  operation 
is  simple,  and  the  prognosis  correspondingly  favourable. 

(2)  In  the  case  of  internal  hcemorrhage  of  the  diffuse  type, 
operation  is  again  invariably  necessary.  The  conditions 
may  here  be  very  unfavourable  for  surgical  interference,  as 
when  the  patient  has  been  brought  nearly  to  death  by  a 
profuse  intra-peritoneal  flooding.  Nevertheless,  the  abdo- 
men must  be  immediately  opened  and  the  bleeding  vessels 
secured.  Success  may  be  obtained  in  cases  apparently 
desperate,  and  the  responsibihty  which  the  operator  un- 
doubtedly takes  in  operating  is,  under  the  circumstances, 
perfectly  justifiable.  Saline  transfusion  mto  the  median 
basilic  vein  should  be  practised  in  the  worst  cases  before  or 
during  the  operation,  and  is  of  the  greatest  assistance  to 
success.  Rapid  work  is  necessary  when  the  patient  is  under 
the  anaesthetic  ;    the  pedicle  should  therefore  be  secured  in 


TUBAL   PREGNANCY  197 

the  simplest  and  most  expeditious  manner  possible.  As 
much  of  the  effused  blood  as  possible  should  be  cleared  away, 
but  time  must  not  be  consumed  in  making  a  complete 
peritoneal  toilet.  One  to  2  pints  of  warm,  sterile,  saline 
solution  may  be  poured  into  the  peritoneal  cavity  before  the 
wound  is  closed  and  left  to  be  absorbed. 

In  cases  of  encysted  internal  hemorrhage  there  is  no  neces- 
sity for  immediate  operation,  but  in  the  majority  of  cases 
recovery  does  not  take  place  without  surgical  interference  of 
some  character.  Palliative  treatme7it  has  been  extensively 
resorted  to  in  such  cases  ;  it  consists  in  confining  the  patient 
strictly  to  bed,  and  trusting  to  absorption  of  the  dead  blood 
taking  place  by  natural  processes.  This  may  undoubtedly 
occur,  but  the  process  is  very  slow  and  many  weeks,  running 
even  into  months,  may  elapse  before  the  effusion  has  dis- 
appeared. Little  or  nothing  can  be  done  by  medical 
measures  to  hasten  absorption.  In  some  cases  a  hsematocele 
may  be  observed  to  increase  steadily  in  size,  notwithstanding 
that  the  patient  is  confined  to  bed  ;  this  is  generally  due  to 
progressive  or  repeated  haemorrhage  from  the  gestation  sac. 
Increase  in  size  may,  however,  be  due  to  infection  of  the 
hsematocele,  and  is  then  usually  accompanied  by  aggravated 
pain  and  fever.  It  follows  that  when  palliative  treatment 
is  decided  upon,  a  guarded  prognosis  should  be  given,  for 
resort  may  ultimately  be  necessary  to  some  operative 
procedure. 

A  pelvic  haematocele  may  be  attacked  from  the  abdomen, 
or  from  the  vagina  by  posterior  colpotomy.  The  advantage 
of  the  former  is  that  the  damaged  tube  is  completely  exposed, 
and  can  be  removed  ;  the  pelvic  peritoneal  cavity  can  be 
properly  cleared  out,  and  the  wound  closed  without  drainage. 
When  the  vaginal  operation  is  adopted,  the  hsematocele  is 
simply  evacuated  and  drained  ;  evacuation  is  necessarily 
incomplete,  and  as  coagulated  blood  does  not  come  away 
freely  by  drainage,  several  weeks  may  elapse  before  the 
cavity  has  completely  closed  up.  The  advantage  is  that  the 
risks  attending  opening  of  the  general  peritoneal  cavity  are 
avoided,  and  in  cases  of  infected  hsematocele  this  risk  is 
undoubtedly  a  serious  one.  Vaginal  drainage  is,  therefore, 
the  operation  of  choice  in  an  infected  hsematocele  ;  in  other 
cases  the  abdominal  operation  is,  as  a  rule,  to  be  preferred  as 


198  ABNORMAL   PREGNANCY 

being  more  thorough  and  followed  by  shorter  convales- 
cence. 

(3)  Secondary  abdominal  pregnancy ^  whether  intra-liga- 
mentary  or  intra-peritoneal,  can  be  dealt  with  only  by 
operative  measures.  The  difficulty  of  distinguishing  the 
two  varieties  has  been  akeady  referred  to  ;  it  practically 
precludes  any  attempt  to  apply  different  methods  of  treat- 
ment to  them.  We  shall  therefore  consider  the  method  of 
dealing  with  such  cases,  firstly,  when  the  fcetus  is  alive  and 
viable,  and  secondly,  when  the  foetus  is  dead. 

(a)  It  is  but  seldom  that  cases  come  under  observation 
while  the  child  is  alive,  and  the  numbers  of  such  cases  which 
have  been  operated  upon  is  relatively  small.  The  ideal 
procedure  in  such  cases  doubtless  is  to  operate  at  once  with 
the  view  of  securing  the  survival  of  the  child  as  well  as  the 
mother.     Two. great  difficulties  have  to  be  encountered. 

In  the  first  place  the  records  show  that  even  if  delivered 
ahve,  the  chances  of  the  child  ultimately  surviving  are  very 
small.  Bland-Sutton  has  collated  eight  cases  operated  upon 
between  the  thirty-fourth  week  and  term,  and  of  these  six 
infants  died  within  a  few  hours  of  birth  ;  the  other  two  did 
not  survive  the  first  year. 

In  the  second  place  the  presence  of  a  quick  placenta  con- 
stitutes a  formidable  technical  difficulty  in  operating.  In 
opening  the  gestation  sac  it  may  be  practicable  to  make  the 
incision  through  a  part  which  is  closely  incorporated  with 
the  abdominal  parietes,  when  the  operation  may  be  con- 
ducted extra-peritoneally  throughout.  With  this  object,  the 
incision  may  be  made  in  the  linea  semilunaris  instead  of  the 
linea  alba.  After  extracting  the  child  and  dividing  the  cord, 
the  membranes  should  be  peeled  off  the  wall  of  the  sac  and 
the  limits  of  the  placenta  thus  defined.  Three  possible 
courses  are  available  for  dealing  with  the  placenta  :  firstly, 
to  peel  it  off  and  control  haemorrhage  by  ligature,  forceps  and 
packing  ;  secondly,  to  leave  it  untouched,  to  keep  the  gesta- 
tion sac  open  by  stitching  its  edges  to  the  lower  part  of  the 
wound,  and  then  to  allow  the  placenta  to  separate  spon- 
taneously ;  thirdly,  to  leave  the  placenta  untouched,  close 
the  wound  completely  and  trust  to  its  absorption  by  natural 
processes.  The  first  course  leads  to  very  profuse  bleeding 
which  is  difficult  to  control ;  although  it  has  been  occasionally 


TUBAL   PREGNANCY  199 

successful,  in  many  cases  the  operator  has  been  obhged  to 
abandon  the  attempt,  and  instead  to  control  the  bleeding  by 
plugging,  and  leave  the  placenta  in  its  place.  If  the  imme- 
diate difficulty  of  controlling  the  haemorrhage  can  be  sur- 
mounted, the  results  are  good.  If  the  second  course  is 
adopted,  an  attempt  may  be  made  a  week  after  the  operation 
to  remove  the  placenta  through  the  opening,  detaching  it 
with  forceps  and  fingers.  Thrombosis  in  the  sub-placental 
vessels  will  probably  prevent  any  serious  haemorrhage. 
Complete  removal  of  the  placenta  in  this  way  is  however, 
impracticable,  and  infection  of  the  remainder  almost 
invariably  occurs,  and  adds  greatly  to  the  risks  of  the  situa- 
tion. If  this  method  is  adopted,  a  counter- opening  should, 
if  possible,  be  made  through  the  posterior  fornix  into  the 
deepest  part  of  the  gestation  sac,  in  order  to  provide  more 
efficient  drainage.  Experience  of  these  alternative  methods 
is  not  at  present  sufficiently  large  to  permit  of  one  being 
definitely  preferred  to  the  others.  The  third  course  has  been 
suggested  but  not  tried  ;  it  is  theoretically  sound  if  complete 
asepsis  in  operating  can  be  guaranteed.  The  least  failure  in 
this  respect  might,  however,  lead  to  disastrous  results. 

The  difficulties  of  dealing  with  the  quick  placenta  have 
induced  many  operators  to  postpone  operative  interference 
until  the  death  of  the  child  has  occurred  in  the  natural  course 
of  events,  no  attempt  being  made  to  save  it. 

(6)  After  the  death  of  the  child,  the  only  maternal  risk  to 
be  considered  is  that  of  infection  of  the  sac.  The  usual 
practice  has  been  to  delay  operation  for  several  weeks  in 
order  to  aUow  time  for  thrombosis  of  the  placental  sinuses  to 
occur  and  thus  facilitate  separation  of  the  placenta.  This  is 
the  safest  course  to  pursue  so  long  as  no  suspicion  of  infection 
has  arisen.  Such  cases  should  all  be  dealt  with,  if  possible, 
by  an  extra-peritoneal  incision  ;  the  placenta  can  then  be 
peeled  off,  oozing  controlled  by  ligature  or  packing,  and 
drainage  established  by  both  the  suprapubic  and  vaginal 
routes. 


Disorders  associated  with  Pregnancy 

Acute    Infectious    Fevers. — Pregnancy   forms    a   seiious 
complication  of  the  acute  exanthemata,  not  because  the 


200  ABNORMAL   PREGNANCY 

severity  of  the  disease  is  therebj^  increased,  but  on  account 
of  the  high  percentage  of  cases  in  which  abortion  or  prema- 
ture labour  occurs.  This  risk  is  common  to  all,  but  appears 
to  be  greatest  in  the  cases  of  small-pox,  scarlet  fever,  and 
tj^hoid.  Abortion  is  probably  brought  about  m  nearly  all 
cases  by  transmission  of  the  disease,  i.e.,  by  hsematogenous 
infection  of  the  ovum.  The  effect  of  high  temperature  m 
causing  abortion  is  doubtful,  and  it  appears  that  the  severity 
of  the  disease  is  the  most  important  factor.  It  has  now  been 
shown  that  nearly  all  the  exanthemata  may  be  thus  trans- 
mitted to  the  foetus.  In  the  case  of  enteric  fever  it  has  been 
shown  that  the  bacillus  may  be  demonstrated  in  the  foetal 
organs,  that  Widal's  reaction  may  be  obtained  from  the 
blood,  and  that  ulceration  of  Peyer's  patches  may  also  be 
fomid  in  the  foetal  intestine. 

Inasmuch  as  pregnane}^  does  not  influence  the  course  of 
the  disease,  obstetric  interference  is  not  as  a  rule  indicated. 
In  cases  of  tj^hoid  or  scarlet  fever  of  exce|)tional  severity, 
induction  of  abortion  would  probably  be  a  useful  prophy- 
lactic measure,  if  undertaken  early  in  the  course  of  the 
disease,  for  if  abortion  should  occur  in  the  critical  third  or 
fourth  weeks  the  maternal  prognosis  would  be  considerably 
prejudiced. 

Chronic  Infections  (Tubercle,  Syphihs,  and  Gonorrhoea). 
— Phthisis  in  women  does  not  unfavourably  affect  fertility, 
nor  does  it  unfavourably  uifluence  the  course  of  pregnancy  ; 
usually  the  resultmg  children  are  well  develoj)ed  and  show  no 
sign  of  tuberculous  disease  when  born.  During  pregnancy 
phthisical  women  often  appear  to  improve  in  health,  but  in 
the  puerperium  the  tuberculous  disease  usually  advances 
more  rapidly.  In  a  certain  number  of  cases  of  acute  miliary 
tuberculosis  or  advanced  jDuhnonary  phthisis,  the  trans- 
mission of  tubercle  bacilli  from  the  mother  to  the  foetus  has 
been  demonstrated,  but  this  occurrence  is  rare.  Only  in 
quite  exceptional  circumstances  does  phthisis  form  an 
indication  for  the  artificial  termination  of  jDregnancy. 

Syphilis  is  the  most  frec^uent  of  all  the  constitutional 
causes  of  jDremature  interruj^tion  of  pregnancy.  In  the  great 
majorit}"  of  instances  the  source  of  uifection  of  the  ovum  is 
paternal ;  whatever  may  be  the  stage  of  the  disease  in  the 
father,  it  is  possible  for  the  foetus  to  be  infected.     The 


SYPHILIS  201 

influence  of  maternal  syphilis  upon  the  ovum  and  upon  the 
course  of  pregnancy  varies  according  to  the  incidence  of  the 
disease.  Women  infected  with  syphilis  just  before  or  at  the 
time  of  conception  miscarry  in  about  three  out  of  every  four 
cases,  the  foetus  showing  definite  signs  of  the  disease.  In  the 
cases  of  women  infected  subsequent  to  conception  but  early 
in  pregnancy  abortion  often  ensues,  but  with  relatively  less 
frequency.  If  the  infection  occurs  late  in  pregnancy,  the 
course  of  pregnancy  may  be  uninfluenced  and  the  foetus  born 
alive  and  apparently  healthy.  Cases  probably  occur  in 
which  a  woman,  impregnated  by  a  man  who,  though  syphili- 
tic, displays  no  local  infective  lesion,  contracts  syphilis  from 
the  foetus  w  utero.  This  is  known  as  conceptional  syphilis, 
and  is  characterised  by  complete  absence  of  all  lesions 
characteristic  of  the  primary  stage.  Sometimes  a  syphilitic 
foetus  is  born  without  any  outward  sign  of  the  disease  being 
recognisable  in  the  mother,  and  even  if  she  suckles  her  child 
she  does  not  become  obviously  infected.  This  is  known  as 
Colles's  law  of  immunity,  but  it  is  doubtful  whether  the 
mother  under  these  circumstances  is  not  in  reality  affected  by 
syphilis  in  an  attenuated  form  ;  the  fact  that  she  does  not 
become  obviously  infected  from  suckling  her  child  appears  to 
support  this  view. 

Until  recent  years  great  controversy  raged  about  the 
question  of  the  transference  of  syphilitic  infection  from  the 
foetus  to  the  mother.  The  question  has,  of  course,  been 
greatly  simplified  by  the  discovery  of  the  biological  test  for 
syphilis  known  as  the  Wassermann  reaction.  The  absolute  re- 
liability of  the  negative  reaction  has  not  yet  been  established, 
and  many  difficulties  beset  it.  But  observations  appear  to 
show  that  in  circumstances  such  as  those  exemplifying 
Colles's  law,  a  positive  Wassermann  reaction  can  rarely  be 
obtained  from  the  mother  except  when  she  is  actually  preg- 
nant. Yet  her  child  may  show  definite  signs  of  the  disease  ; 
and  women  who  have  once  been  infected  with  '  conceptional ' 
syphilis  may  continue  to  give  birth  to  syphilitic  infants  even 
when  married  to  men  who  are  free  from  the  disease,  showing 
that  the  disease  is  present  in  some  form  which  is  capable  of 
transmission.  The  accuracy  of  Colles's  observations  is  there- 
fore supported  by  the  results  of  the  test. 

As  syphilis  is  a  bacterial  disease,  these  observations  imply 


202  ABNORMAL   PREGNANCY 

that  the  specific  organism  is  transmitted  with  the  sperma- 
tozoa, and  that  the  ovum  is  either  infected  at  the  moment  of 
fertilisation,  or  that  the  infection  attacks  it  very  soon  after- 
wards. The  frequency  with  which  abortion  occurs  may  be 
explained  partly  by  diseased  conditions  arising  in  the  foetus 
or  its  membranes,  or  in  the  decidua,  and  partly  by  the 
general  maternal  infection  exerting  a  toxic  effect  upon  the 
growing  ovum.  The  latter  is  rendered  probable  by  the  fact 
that  morbid  conditions  are  not  always  found  in  the  ovum  or 
decidua  in  these  cases.  In  all  syphihtic  women,  however, 
there  is  a  very  high  percentage  of  abortion  ;  fertihty  is  not 
lessened,  and  of  a  series  of  pregnancies  some  may  terminate 
in  miscarriage,  others  in  the  birth  of  syphihtic  infants,  while 
one  or  other  of  the  series  may  yield  an  infant  showing  no 
signs  of  the  disease  at  birth.  According  to  statistics  published 
by  Hochsinger,  not  more  than  from  9  to  10  per  cent,  of 
the  children  borne  by  syphilitic  mothers  are  free  from 
signs  of  the  disease  at  birth,  and  of  this  small  number  a 
certain  proportion  develop  signs  of  syphiKs,  such  as  a 
positive  Wassermann  reaction,  during  the  first  six  months 
of  life. 

Anti-syphintic  treatment  of  both  parents  is,  of  course, 
required  in  all  cases  where  there  is  evidence  of  the  existence 
of  the  disease  in  either,  and  even  in  cases  of  paternal  syphihs, 
when  the  mother  is  apparently  unaffected,  full  treatment 
with  salvarsan  or  mercurial  injection  should  be  advised.  A 
sjrphilitic  infant  should  never  be  suckled  by  a  wet  nurse,  nor 
should  a  syphilitic  mother  ever  be  allowed  to  suckle  her  child, 
for  the  specific  organisms  may  possibly  be  transmitted 
through  the  milk. 

Gonorrhoea.- — When  this  disease  is  contracted  during 
pregnancy  it  is  apt  to  give  rise  to  a  very  acute  form  of  vulvo- 
vaginitis, associated  with  extensive  redness  and  oedema  of 
the  skin  surfaces,  and  the  formation  of  diphtheritic  patches 
upon  the  mucous  membranes.  The  acute  form  almost 
necessarily  ends  in  abortion  and  is  accompanied  by  the 
gravest  risks  of  upward  spread  of  the  infection  to  the  uterus, 
the  Fallopian  tubes  and  the  pelvic  peritoneum.  Acute 
decidual  endometritis,  gonorrhoeal  peritonitis,  or  an  acute 
abscess  of  the  tubes  will  then  result,  all  these  conditions  being 
of  the  most  serious  nature. 


HEART   DISEASE  203 

Chronic  gonorrhcBal  infection  is  most  commonly  met  with 
in  the  form  of  endocervicitis  or  vulvo-vaginitis  accompanied 
by  a  purulent  discharge.  The  former  condition  is  usually 
associated  with  sterility,  but  it  is  not  an  absolute  bar  to  con- 
ception. Vulvo-vaginitis,  on  the  other  hand,  has  little 
influence  either  upon  conception  or  on  the  course  of  preg- 
nancy. In  many  instances  impregnation  and  infection 
occurred  at  the  same  time,  but  so  long  as  the  disease  is  not 
acute,  abortion  is  uncommon,  and  it  is  probably  quite  excep- 
tional for  the  uterus  to  be  invaded  by  the  organisms.  After 
abortion  or  labour,  however,  in  all  cases  there  is  the  risk  that 
the  disease  may  spread  to  the  Fallopian  tubes,  ovaries,  and 
pelvic  peritoneum  with  the  most  serious  or  even  fatal  con- 
sequences. During  labour,  gonorrhoeal  vaginitis,  whether 
acute  or  chronic,  entails  serious  risks  of  infection  of  the  eyes 
or  mouth  of  the  foetus.  Gonorrhoeal  discharges  at  all  stages 
of  pregnancy  accordingly  require  careful  local  treatment  by 
vaginal  douching  and  other  measures,  the  details  of  which  are 
described  in  text-books  of  gynaecology.  It  must  also  be 
remembered  that  gonorrhoeal  discharges  are  infectious  at  all 
stages,  and  even  when  the  specific  organism  has  disappeared 
other  pathogenic  bacteria  may  be  present ;  the  greatest  care 
must,  therefore,  be  taken  to  prevent  the  transmission  of 
infection  to  other  patients. 

Malaria. — This  disease  is  not  often  seen  in  this  country  in 
connection  with  pregnancy.  In  countries  where  malaria  is 
endemic  it  is  however  of  frequent  occurrence,  and  experience 
shows  that  the  disease  exerts  little,  if  any,  unfavourable 
influence  upon  pregnancy.  Attacks  of  malaria  are  apt  to  be 
more  frequent  and  severe  than  usual  when  pregnancy  has 
occurred,  and  recrudescence  of  the  disease  is  not  infrequent 
in  cases  in  which  it  has  become  quiescent.  It  is  said  that 
the  infant  of  a  malarial  mother  often  suffers  from  malarial 
attacks  in  infancy,  but  it  does  not  appear  that  the  charac- 
teristic Plasmodium  has  been  detected  in  the  foetal  blood. 
Malaria  may  be  treated  freely  with  quinine,  for  the  oxytocic 
properties  of  the  drug  are  said  to  be  very  feeble  in  the  sub- 
jects of  this  disease,  a  result  which  may  probably  be  referred 
to  tolerance  established  by  previous  administration  of  large 
doses. 

Diseases  of  the  Heart  and  Circulatory  System. — Chronic 


204  ABNORMAL   PREGNANCY 

valvular  disease  of  the  heart  is  not  infrequently  met  mth  in 
pregnant  women.  In  a  series  of  cases  collated  by  Fellner, 
in  about  70  per  cent,  the  mitral  valve  was  the  one  affected, 
mitral  insufficiency,  either  alone  or  combined  with  stenosis, 
being  much  commoner  than  simple  stenosis,  which  is  but 
rarely  met  with,  in  pregnancj^  Lesions  of  both  the  aortic 
and  the  mitral  valves  may  also  be  met  mth,  but  simple  aortic 
lesions  are  rare  in  women. 

Of  valvular  lesions  the  most  serious  of  all  to  the  pregnant 
woman  is  mitral  stenosis  ;  many  observers  have  estimated 
the  mortahty  of  this  lesion  at  about  50  per  cent.  Mtral 
incompetence  and  aortic  lesions  of  both  kinds  are  not  nearly 
so  serious  as  this  ;  only  when  compensation  has  broken  down 
are  these  lesions  of  serious  prognosis.  Owing  to  the  high 
mortality  of  mitral  stenosis,  many  authorities  have  suggested 
that  women  suffering  from  this  affection  should  be  advised 
not  to  incur  the  risk  of  pregnancy.  Li  other  forms  of  valvu- 
lar disease  it  is  certainly  unnecessary  for  this  advice  to  be 
given,  save  in  cases  where  failure  of  compensation  has 
previously  occurred,  either  in  connection  with  pregnancy  or 
from  some  other  cause.  In  such  cases  the  gra^^ty  of  the 
risk  attending  pregnancy  is  increased  to  an  untold  extent. 

As  long  as  compensation  is  maintained  a  woman  suffering 
from  mitral  lesions  may  pass  successfully  through  a  number 
of  pregnancies  without  running  any  serious  risk.  Irregular 
haemorrhage  during  the  early  months  is  not  uncommon,  and 
there  is  a  marked  tendencj^  to  the  occurrence  of  abortion  or 
premature  labour.  But  such  women  are  in  constant  danger 
of  a  cardiac  breakdown  from  which  the  most  serious  conse- 
quences may  ensue.  It  may  be  precipitated  hj  a  concm'rent 
ilhiess,  such  as  a  fresh  attack  of  rheumatism  or  some  pul- 
monary complication  ;  often  it  appears  to  be  solely  the  result 
of  the  pregnancy.  Compensation  is  most  likely  to  break 
down  in  the  later  months  of  pregnancy,  or  during  labour,  or  in 
the  course  of  the  puerperium.  The  first  few  hours  after  labour 
are  perhaps  the  most  serious,  on  accomit  of  the  sudden  fall  in 
blood  pressure  which  foUows  the  evacuation  of  the  uterus. 

The  greatest  care  must  therefore  be  taken  to  maintain 
compensation  during  pregTiancy  and  avoid  over-strain  ;  so 
long  as  this  is  successful,  pregnancy  will  continue  favourably. 

There  is  no  doubt  however  that  every  pregnancy  inflicts 


HEART   DISEASE  205 

further  damage  upon  a  diseased  heart  and  reduces  its 
reserve  of  force  ;  it  therefore  shortens  the  patient's  expecta- 
tion of  hfe  considerably,  even  if  all  should  go  well.  Signs 
of  failing  compensation,  such  as  anasarca,  scanty  and 
albuminous  urine,  bronchitis,  pulmonary  oedema,  or  marked 
irregularity  of  the  pulse,  should  be  treated  by  absolute 
rest  in  bed,  simple  diuretic  and  aperient  drugs,  and  cardiac 
tonics,  such  as  digitalis  or  strophanthus,  in  small  doses. 
If  serious  symptoms,  such  as  dyspnoea  and  cyanosis,  or 
pulmonary  oedema  supervene,  venesection,  to  the  extent  of 
8  to  10  ounces  of  blood,  will  afford  immediate  relief.  The 
most  serious  result  of  the  breakdown  is  the  accumulation  of 
•fluid  in  the  chest,  hydrothorax  and  hydropericardium,  as 
these  add  a  mechanical  obstacle  to  the  action  of  the  already 
over-loaded  heart.  These  conditions  must  be  relieved  by 
tapping. 

Generally  speaking  treatment  should  be  first  directed  to 
restoring  the  heart's  action  rather  than  to  interfering  with 
the  course  of  pregnancy.  If  the  breakdown  has  occurred 
in  the  first  half  of  pregnancy,  abortion  should  be  induced 
as  soon  as  the  condition  has  improved,  for  it  is  certain  that 
the  heart  will  not  stand  the  severe  strain  of  the  later 
months.  The  process  of  abortion  is  easy,  and  the  patient 
will  be  rescued  from  a  grave  danger.  When  the  breakdown 
occurs  in  the  second  half  of  pregnancy,  the  same  general 
treatment  should  be  followed,  but  this  often  fails,  and 
then  to  terminate  pregnancy  gives  the  patient  her  only 
chance  of  recovery,  for  if  compensation  breaks  down  seriously 
towards  the  end  of  pregnancy  her  prospect  of  surviving  the 
strain  of  labour  is  very  poor. 

If  pregnancy  should  occur  in  a  woman  who  has  previously 
suffered  a  failure  of  compensation,  whether  in  pregnancy  or 
not,  abortion  should  be  at  once  induced.  In  the  later 
months  of  pregnancy  the  success  of  interference  is  more 
doubtful,  for  the  reasons  just  stated.  Operative  measures 
for  the  rapid  evacuation  of  the  uterus  are  probably  less  risky 
than  the  induction  of  abortion  or  labour  by  the  slow 
methods,  for  labour  pains  involve  a  serious  strain  on  the 
heart  ;  when  the  child  is  viable  there  is  no  reason  to  delay 
an  operation  which  is  inevitable.  The  course  which  offers 
the  best  chance  is  therefore  to  deliver  by  Csesarean  section, 


206  ABNORMAL   PREGNANCY 

and  thus  avoid  the  pains  of  labour  altogether.  If  this  is 
done  a  general  anaesthetic  should  not  be  administered,  the 
operation  being  done  under  spinal  anaesthesia  or  local 
cutaneous  anaesthesia. 

Varices  in  the  lower  extremities  and  labia  majora  are  apt 
to  become  greatly  aggravated  by  pregnancy,  giving  rise  to 
pain  and  inabihty  to  walk.  Vulval  varices  sometimes 
rupture  from  traumatism,  leading  to  profuse  haemorrhage, 
which  has  been  known  to  prove  fatal  in  the  absence  of  proper 
surgical  aid. 

Renal  Diseases. — The  influence  of  chronic  nephritis 
upon  pregnancy  has  already  been  referred  to  when  con- 
sidering the  subject  of  albuminuria.  To  distinguish  between 
this  condition  and  the  transient  renal  changes  characteristic 
of  the  '  pregnancy  kidney  '  may  be  somewhat  difficult  when 
the  existence  of  chronic  nephritis  has  been  unsuspected 
before  conception.  In  the  following  points  chronic  nephritis 
with  pregnancy  will  be  found  to  differ  from  the  albuminuria 
of  pregnancy  : 

(1)  Albuminuria  and  oedema  appear  much  earlier  (see 
p.  114). 

(2)  (Edema  is  likely  to  affect  the  face  and  upper 
extremities. 

(3)  Characteristic  changes  may  be  found  in  the  arteries, 
the  heart,  and  the  retina  (exudative  retinitis  may,  however, 
occur  in  the  albuminuria  of  pregnancy). 

(4)  Intercurrent  attacks  of  acute  nephritis  may  occur. 

(5)  Epithelial  casts  and  renal  cells  may  be  found  in  the 
urine. 

In  general  terms  it  may  be  said  that,  on  the  one  hand, 
the  effect  of  pregnancy  usually  is  to  aggravate  the  renal 
disease  ;  on  the  other,  the  disease  usually  causes  the  preg- 
nancy to  terminate  prematurely,  tends  to  destroy  the  foetus 
by  inducing  j)lacental  degeneration,  and  may  cause  the  death 
of  the  mother  from  uraemia.  Convulsions  which  ensue  under 
these  circumstances  must  be  regarded  as  mainly  uraemic  in 
origin.  The  foetal  mortality  in  chronic  nephritis  is  very  high 
indeed. 

From  these  considerations  it  will  be  a23parent  that  preg- 
nancy in  the  subjects  of  chronic  nephritis  involves  grave 
risks.     A  patient  who  has  survived  an  attack  of  uraemia  in  a 


RENAL   DISEASES  207 

previous  pregnancy  should  not  be  allowed  to  incur  the  risks 
again  ;  and  if  conception  does  take  place,  abortion  should  be 
induced  without  delay.  In  the  case  of  a  prim 'gravida,  or  if 
previous  pregnancy  has  not  been  attended  with  serious  com- 
plications, palliative  treatment  may  be  adopted  ;  but  the 
chances  of  the  patient  bearing  a  living  child  are  by  no  means 
good.  The  occurrence  of  an  intercurrent  acute  attack  of 
nephritis  almost  always  ends  in  abortion. 

It  will  be  obvious  that  pregnancy  with  chronic  nephritis 
calls  for  the  most  careful  observation  of  the  patient's  con- 
dition. Regular  weekly  examination  of  the  urine  should  be 
made,  including  a  quantitative  estimation  of  urea.  Restric- 
tion of  proteid  elements  in  the  diet  is  desirable  from  the 
beginning,  and  this  of  itself  will  result  in  a  comparatively 
low  output  of  urea.  Regular  and  frequent  estimation  is 
accordingly  the  only  way  in  which  a  diminution  due  to 
toxaemia  can  be  recognised.  Irregularities  of  diet,  fatigue, 
and  chill  are  especially  to  be  avoided,  and  it  must  be  recol- 
lected that"  the  premonitory  symptoms  of  eclampsia  (see 
p.  528)  include  such  inconsiderable  symptoms  as  headache, 
functional  disturbances  of  vision,  and  complaints  of  '  indi- 
gestion.' During  the  later  months  of  pregnancy  the  con- 
dition of  the  foetus  should  be  watched  ;  if  the  foetus  dies  it  is 
desirable  to  induce  labour  without  delay,  for  the  risks  attend- 
ing the  condition  are  not  greatly  diminished  until  the  uterus 
has  been  evacuated. 

Bacillus  Coli  Infection  of  the  Urinary  Tract:  Pyelitis  of 
Pregnancy. — It  is  only  within  the  last  twenty  years  that  the 
occurrence  of  an  acute  form  of  pyelitis,  or  pyelonephritis, 
during  pregnancy  has  been  recognised.  It  was  observed  that 
the  condition  could  be  cured  by  inducing  abortion,  and  it  was 
assumed  in  consequence  that  pregnancy  was  the  immediate 
cause,  as  the  earlier  name  '  Pyelitis  of  Pregnancy  '  implies. 
It  has  however  been  established  that  in  practically  all  cases 
the  disease  results  from  bacillus  coli  infection,  usually  as  a 
pure  infection,  but  sometimes  mixed,  pyogenic  organisms 
being  also  present.  Further,  although  the  renal  pelvis  is  the 
position  in  which  the  most  marked  lesions  occur,  the  kidney 
substance,  the  ureter,  and,  though  more  rarely,  the  bladder, 
also  may  be  infected.  It  is  accordingly  better  to  name  the 
condition  '  Bacillus  Coli  Infection  of  the  Urinary  Tract.' 


208  ABNORMAL   PREGNANCY 

The  condition  seldom  occurs  earlier  in  pregnancy  than  the 
fourth  month  ;  occasionally  an  acute  attack  of  great  severity 
occurs  in  the  puerjDerium,  when  care  will  be  required  to 
distinguish  it  from  acute  septicaemia  (p.  581).  It  may 
assume  either  an  acute  or  a  chronic  form,  and  as  a  rule 
there  have  been  no  symptoms  of  cystitis  or  of  renal  disease 
previous  to  the  pregnancy. 

In  the  acute  form  the  patient  is  suddenly  seized  with  acute 
abdominal  pain,  sometimes  attended  with  shivering,  and 
leading  after  a  few  hours  to  abdominal  distension  and  some- 
times to  vomiting.  The  pain,  diffused  at  first,  usually  settles 
down  to  the  right  side,  but  in  a  small  proportion  of  cases  the 
left  is  the  affected  side.  The  bowels  are  usually  constipated 
and  the  tongue  furred.  The  kidney,  when  palpable,  is 
tender  and  may  be  felt  to  be  enlarged  ;  often  there  is  well- 
marked  rigidity  of  the  rectus  muscle  over  it,  and  so  much 
tenderness  that  detailed  palpation  is  impracticable.  Some- 
times the  pain  on  pressure  is  felt  chiefly  in  the  costo-vertebral 
angle.  The  gravid  uterus  usuallj^  shows  no  abnormality,  but 
tenderness,  with  thickening  of  the  terminal  portion  of  the 
ureter  (usually  the  right),  may  be  detected  jper  vaginam  on 
deep  palpation  at  the  sides  of  the  cervix  anteriorly.  Th« 
temperature  may  be  raised  to  103°  to  104°  F.,  and  the  fever 
continues  irregularly  for  some  days  unless  controlled  by 
treatment.  Sometimes  rigors  occur  and  the  general  condi- 
tion of  the  patient  is  so  much  affected  as  to  give  rise  to 
anxiety. 

On  examination  of  a  catheter  specimen  of  the  urine  it 
wiU  usually  be  found  distinctly  acid,  less  often  it  has  been 
observed  to  be  neutral  or  alkaline.  It  is  turbid  and  contains 
flocculent  debris.  In  the  great  majority  of  cases  culture 
methods  yield  a  pure  bacillus  coli;  sometimes  pyogenic 
organisms  are  also  present.  There  are  no  renal  casts,  but 
the  deposit  may  contain  a  little  blood,  and  there  is  always 
a  good  deal  of  pus,  shed  epithelial  cells,  and  epithelial  debris 
from  the  urinary  passages.  The  quantity  of  urine  is  usually 
small,  and  there  is  no  offensive  odour.  A  trace  of  albumen 
can  usually  be  found.  In  many  cases  the  onset  is  less  acute 
than  this,  but  fever  and  severe  pain  m  the  abdomen  or  flank 
are  invariably  met  with. 

In  the  chronic  form  the  symptoms  are,  of  course,  less 


BACILLUS  COLI  INFECTION  209 

characteristic.  There  is  often  slight  irregular  fever,  but  this 
is  not  invariable,  and  the  patient  complains  of  backache  and 
sometimes  of  persistent  irritability  of  the  bladder.  On 
palpation  the  kidney  is  sensitive  and  may  be  enlarged. 

The  right  kidney  shows  a  marked  predisposition  to  this 
disease,  but  not  to  the  extent  that  was  at  one  time  believed. 
Out  of  129  cases  collated  by  Albeck  and  Lenharz,  in  67  the 
right  kidney  alone  was  affected,  in  26  the  left  kidney  alone, 
and  in  36  both  right  and  left  were  affected.  It  has  been 
shown  further  by  autopsy,  and  by  direct  observation  upon 
cases  submitted  to  operation,  that  the  ureter  may  become 
dilated,  at  any  rate  in  its  abdominal  part,  upon  the  affected 
side.  It  is  generally  agreed  that  this  dilatation  does  not  affect 
the  pelvic  portion  of  the  ureter,  i.e.,  that  it  is  only  found  in 
the  part  which  lies  above  the  pelvic  brim.  It  will  be 
recollected  that  ureteral  dilatation  similar  to  this  has  been 
observed  in  autopsies  on  cases  of  eclampsia. 

Acute  catarrhal  inflammation  is  found  in  the  renal  pelvis 
and  ureter  ;  sometimes,  but  this  is  very  rare,  there  is  also 
cystitis.  From  obstruction  to  the  ureter  a  pyonephrosis 
may  supervene. 

Causation. — This  disease  is  in  all  cases  due  to  infection  of 
the  urinary  tract  by  the  bacillus  coli.  When  other  organisms 
are  also  found  in  the  urine  secondary  infection  has  probably 
occurred.  The  manner  in  which  the  bacillus  coli  obtains 
access  is  at  present  unsettled.  There  are  three  possible 
routes  to  be  considered.  The  first  and  most  obvious  is  an 
ascending  infection  per  urethram ;  as  Williamson  has 
pointed  out,  this  may  occur  either  by  direct  infection  of 
stagnant  urine  above  the  ureteral  block,  or  by  the  peri- 
ureteral lymphatics.  By  this  route  the  bladder  would  first 
be  involved,  but  clinically  the  special  symptoms  of  cystitis 
are  seldom  observed  in  the  early  stages.  The  second  is  by 
the  circulation,  the  organisms  passing  through  the  kidney 
and  attacking  the  mucous  membrane  of  the  renal  pelvis. 
The  third  is  a  direct  infection  from  the  bowel,  the  organisms 
passing  from  the  colon  through  the  peri-ureteral  cellular 
tissue  to  gain  access  to  the  ureter,  or  possibly  to  the  kidney. 
Even  if  the  route  by  which  the  infection  travels  were  known, 
we  do  not  know  what  causes  the  bacillus  coli  to  assume 
pathogenic  activity  during  pregnancy. 

E.M.  14 


210  ABNORMAL   PREGNANCY 

A  mechanical  explanation  has  been  suggested,  viz.,  that 
pressure  exerted  by  the  gravid  uterus  upon  the  ureter  at  the 
pelvic  brim  may  predispose  to  the  occurrence  of  infection  by 
leading  to  retention  of  urine  above  the  line  of  jDressure.  The 
infection  may,  however,  occur  in  the  early  months  before 
the  uterus  is  large  enough  to  compress  the  ureter  ;  and 
further,  other  conditions  such  as  uterine  tumours  likely  to 
produce  mechanical  obstruction  of  the  ureter  do  not  lead  to 
urinary  infection. 

Diagnosis. — ^An  acute  attack  of  pyehtis,  with  its  sudden 
febrile  onset  and  its  preponderance  on  the  right  side,  must 
be  carefully  distinguished  from  acute  appendicitis,  which  it 
resembles  in  many  respects.  Acute  cholecystitis  may  also 
give  rise  to  a  similar  clinical  picture.  Ultimately  the  diag- 
nosis depends  upon  the  condition  of  the  urine,  and  the 
importance  of  carefully  examining  a  catheter  specimen  in 
cases  of  doubt  must  be  borne  in  mind.  The  urine  is  acid, 
more  or  less  turbid,  and  contains  a  microscopic  amount  of 
pus  ;    culture  is  required  to  demonstrate  the  organisms. 

Treatment. — In  an  acute  case  the  patient  should  be  kept 
in  bed,  the  diet  restricted  to  fluids,  chiefly  milk,  and  large 
doses  of  an  alkaline  diuretic,  such  as  citrate  or  acetate  of 
potash  aclmhiistered  with  the  object  of  increasing  the  amount 
and  reducing  the  acidity  of  the  urine.  It  appears  that  an 
acid  urine  forms  a  better  culture  medium  for  the  bacillus 
coli  than  an  alkaline  urine.  The  acute  symptoms  usually 
subside  in  a  few  days  if  a  free  flow  of  urine  can  be  mamtained, 
and  it  is  probable  that  much  of  the  initial  severity  of  the 
attack  results  from  dilatation  of  the  renal  pelvis  and  ureter. 
The  bowels  must  be  freel}^  moved  exevy  day.  The  urinary 
infection  can  be  directly  attacked  in  two  other  ways,  viz.,  by 
urinary  antiseptics  and  by  autogenous  vaccines.  The  most 
powerful  urmary  antiseptic  is  the  substance  known  as 
urotropin,  a  synthetic  compound  prepared  from  form- 
aldehyde (formahn).  This  body  is  efficient  only  in  an  acid 
medium,  and  it  is  desii'able  to  administer  with  it  a  salt  which 
tends  to  increase  the  acidity  of  the  urine,  such  as  acid  sodium 
X^hosjDhate.  Ten  grains  of  urotropin  with  twenty  grains  of 
acid  sodium  phos]3hate  may  be  given  three  times  a  day.  It 
is  clear  that  this  line  of  treatment  cannot  be  combined  with 
the  administration  of  alkaline  diuretics,   and  it  has  been 


BACILLUS  COLI   INFECTION  211 

found  best  to  withhold  urinary  antiseptics  until  the  acute 
symptoms  have  subsided.  The  results  obtained  with  vaccines 
.  are  unreliable,  and  this  treatment  is  rarely  required.  Medi- 
cinal measures  usually  suffice  to  relieve  the  symptoms,  but 
the  specific  organism  often  persists  in  the  urine  after  the 
symptoms  have  all  disappeared. 

If  medical  treatment  fails  to  relieve  the  condition,  two 
other  methods  of  treatment  are  available,  viz.,  induction  of 
labour  and  nephrotomy.  The  results  of  inducing  labour 
have  been  almost  invariably  favourable,  and  this  clinical 
fact  lends  support  to  the  theory  of  mechanical  obstruction 
of  the  ureter  already  referred  to.  Nephrotomy  should  be 
reserved  for  cases  in  which  all  other  measures  have  failed, 
or  in  which  the  urgency  of  the  symptoms  suggests  the  possi- 
bility of  pyonephrosis,  or  of  infection  of  the  renal  cortex. 

Catheterisation  of  the  ureter,  either  alone  or  with  irriga- 
tion of  the  renal  pelvis,  is  sometimes  practised. 

Diseases  of  the  Liver. — Pregnancy  is,  in  some  unexplained 
manner,  one  of  the  predisposing  causes  of  acute  yellow 
atrophy  of  the  liver.  This  rare  disease  induces  changes  in 
the  organ  similar  to  those  often  found  in  fatal  cases  of 
puerperal  eclampsia.  Jaundice  in  pregnant  women  is 
always  a  somewhat  serious  symptom,  owing  to  the  fact  that 
it  may  indicate  the  onset  of  acute  yellow  atrophy.  No 
treatment  is  known  which  will  arrest  the  course  of  this 
malady. 

Diabetes  is  seldom  found  in  association  with  pregnancy, 
probably  because  it  exerts  an  influence  unfavourable  to 
conception.  The  frequent  occurrence  of  traces  of  lactose 
in  the  urine  of  healthy  pregnant  and  nursing  women  must 
be  recollected,  and  due  care  exercised  before  arriving  at  a 
diagnosis  of  diabetes?  The  prognosis  is  mainly  influenced  by 
the  severity  of  the  disease  ;  in  moderate  cases  pregnancy 
and  labour  may  end  favourably  both  to  mother  and  child  ; 
in  severe  cases  there  appears  to  be  a  special  risk  of  diabetic 
coma  in  the  later  months  or  during  labour.  Hydramnios  is 
said  to  be  frequently  associated  with  diabetes,  the  amniotic 
fluid  containing  sugar. 

Diseases  of  the  Nervous  System. — Neuritis,  supposed  to 
be  of  toxsemic  origin,  sometimes  occurs  during  pregnancy  ; 
it  may  affect  a  single  nerve  or  may  be  multiple.     Severe 

14—2 


212  ABNORMAL   PREGNANCY 

pain,  limited  to  the  distribution  of  the  affected  nerve,  is  the 
prominent  symptom.     It  disappears  rapidly  after  labour. 

Chorea  is  not  infrequently  met  with  during  pregnancy  ; 
it  is  commoner  in  the  first  than  in  a  subsequent  pregnancy. 
In  about  two-thirds  of  the  cases  there  is  a  previous  history 
of  rheumatism,  or  of  chorea  and  rheumatism  combined.  By 
many  obstetric  waiters  it  is  regarded  as  a  toxsemic  disease, 
but  no  definite  post-mortem  evidence  of  the  changes 
characteristic  of  death  from  pregnancy  toxaemia  has  so  far 
been  discovered,  although  a  considerable  number  of  cases 
that  have  terminated  fatally  have  been  recorded.  There  is 
therefore  not  the  same  sound  reason  for  including  it  in  the 
toxsemic  diseases  as  there  is  in  the  case  of  eclampsia  and 
pernicious  vomitmg.  It  is  better  to  regard  it  as  a  disease 
of  the  nervous  system,  the  occurrence,  or  the  recrudescence, 
of  which  is  favoured  m  some  way  by  pregnancy. 

The  majority  of  cases  of  chorea  are  of  a  mild  type  ; 
spontaneous  abortion  occurs  in  from  10  to  15  per  cent.,  but 
very  few  cases  terminate  fatally.  At  the  same  time  it 
must  be  recognised  that  cases  of  great  severity  sometimes 
occur  which  end  in  death  in  spite  of  energetic  treatment, 
including  the  induction  of  abortion.  Lepage  has  recently 
collected  77  fatal  cases,  and  in  nearly  half  of  these  abortion 
failed  to  arrest  the  course  of  the  disease.  Owing  to  the 
variability  in  type  the  mortality  rate  is  difficult  to  deter- 
mine and  is  placed  variously  at  from  5  to  40  per  cent,  by 
different  writers.  Andrews  and  HaU  have  reported  40  cases 
at  the  London  Hospital  with  5  deaths,  equal  to  12' 5  per 
cent. ;  in  the  fatal  cases  abortion  occuired  in  two  spon- 
taneously, and  in  two  others  it  was  induced.  Fletcher 
Shaw  has  recorded  a  series  of  32  consecutive  cases  in 
Manchester  without  a  death.  "^ 

In  cases  of  exceptional  severity  where  a  fatal  termination 
may  be  feared,  the  choreic  movements  become  so  intense 
as  to  prevent  the  taking  of  nourishment  and  to  hmder 
sleep  ;  there  may  also  be  delirium,  rise  of  temperatui^e  and 
of  pulse  rate,  the  appearance  of  a  morbilliform  eruption  and 
retention  of  urine.  The  causation  of  the  latter  symptom, 
which  Lepage  regards  as  pecuharly  grave,  is  unknown. 

The  treatment  of  this  disease  in  mild  cases  is  satisfactory, 
and  as  a  rule  pregnancy  ends  favoiu-ably  both  to  the  mother 


CHOREA  213 

and  the  child.  Absolute  rest  in  bed  and  careful  feeding 
are  very  important.  Sedatives  such  as  bromide  and  chloral 
should  be  used  sparingly,  and  chiefly  for  the  purpose  of 
ensuring  sleep  when  this  is  rendered  necessary.  The  bowels 
should  be  kept  023en  freely,  and  the  functions  of  the  skin 
and  kidneys  kept  active  by  the  '  eliminative '  methods 
described  in  connection  with  the  treatment  of  pernicious 
vomiting. 

In  cases  which  belong  to  the  '  severe  '  class,  and  in  which 
the  symptoms  of  danger  just  mentioned  appear,  pregnancy 
should  be  terminated  by  a  method  which  necessitates  the 
minimum  of  ojierative  interference,  and  is  suitable  to  the 
period  to  which  pregnancy  has  advanced  (see  p.  653).  The 
undoubted  influence  of  pregnancy  in  the  causation  of  the 
disease  is  a  sufhcient  justification  for  this  procedure,  but  it 
will  be  recollected  that  a  favourable  result  for  this  operation 
cannot  be  with  certainty  anticipated. 

Herpes  gesfMio7iis. — This  rare  affection  is  believed  to  be 
a  neuritis  of  toxsemic  origin.  It  is  characterised  by  multiform 
skin  lesions,  the  commonest  type  being  crops  of  papules, 
vesicles,  or  pustules  of  herpetiform  character  ;  they  are  distri- 
buted chiefly  upon  the  buttocks,  the  flanks,  the  forearms,  and 
the  back  of  the  thighs.  Sometimes  the  disease  affects  the  skin 
of  the  whole  body,  is  very  intractable,  and  may  cause  serious 
exhaustion  from  uncontrollable  irritation  and  want  of  sleep. 

Appendicitis. — This  disease  is  comparatively  rarely  seen 
in  connection  with  pregnancy.  There  is  no  clinical  evidence 
that  pregnant  women  display  any  special  liability  either  to 
an  initial  attack  or  to  recurrences.  The  seriousness  of  the 
complication  when  it  does  occur  is,  however,  unquestionable, 
especially  in  the  later  months  of  pregnancy.  When  pus  is 
present  there  is  great  risk  of  the  uterine  contents  becoming 
infected,  even  when  the  abscess  has  been  treated  by  drainage  ; 
miscarriage  occurs  in  90  per  cent,  of  such  cases  (Abrahams), 
and  the  baciUus  coli  has  been  found  in  the  foetal  blood. 
Following  the  uterine  infection  there  are  risks  of  septicaemia, 
or  of  suppurative  disease  of  the  uterine  appendages,  in  the 
puerperium.  These  special  risks  may  be  regarded  as  an 
indication  for  prompt  surgical  interference  when  appendicitis 
occurs  during  pregnancy,  and  the  indication  is  even  more 
emphatic  when  the  illness  is  a  recurrence  and  not  an  initial 


214  ABNORMAL  PREGNANCY 

attack.  Induction  of  abortion  or  of  premature  labour  is  not 
advisable  as  an  alternative  to  an  operation  ;  it  is  reasonable 
to  suppose  that  the  rapid  reduction  in  size  of  the  uterus  might 
be  the  means  of  disturbing  protective  or  limiting  adhesions, 
thus  facilitating  generalisation  of  infection  over  the  peritoneal 
cavity.  But  before  the  evacuation  and  drainage  of  an 
appendicular  abscess  infection  of  the  uterine  contents  may 
have  already  occurred  ;  the  risks  are  therefore  not  entirely 
eliminated  by  the  operation.  As  a  rule  an  infected  ovum  is 
quickly  expelled  without  interference,  but  the  advisability 
of  inducing  abortion  by  one  of  the  methods  described  on 
p.  653,  after  the  abscess  has  been  evacuated,  must  be  care- 
fully considered.  The  interests  of  the  mother  are  predomi- 
nant, for  the  chances  of  the  survival  of  the  child,  when  viable, 
are  very  slight. 

Ovarian  Tumours. — The  presence  of  a  unilateral  ovarian 
cyst,  if  uncomplicated,  forms  no  hindrance  to  conception  ; 
bilateral  soHd  tumours,  whether  benign  or  malignant,  are 
rarely  found  in  association  with  pregnancy.  Single  cysts  of 
moderate  size,  which  rise  into  the  abdominal  cavity  along 
with  the  uterus  as  it  develops,  give  rise  to  no  symptoms  and 
are  often  not  discovered  until  labour  sets  in  ;  or  even  until, 
during  the  puerperium,  the  size  of  the  abdomen  draws  atten- 
tion to  their  presence.  Small  tumours  which  during  preg- 
nancy remain  in  the  pouch  of  Douglas  are  subjected  to  con- 
siderable pressure,  and  may  give  rise  to  pain  and  interference 
with  the  functions  of  the  bladder  and  rectum.  They  may 
obstruct  labour  (see  p.  433),  and  they  not  infrequently  give 
rise  to  serious  trouble  during  the  puerperium,  from  axial 
rotation  of  the  pedicle  or  from  injury  received  in  labour.  As 
a  rule,  ovarian  tumours  discovered  during  pregnancy  should 
be  at  once  removed  ;  ovariotomy  in  pregnant  women  is  no 
more  serious  than  in  the  non-pregnant.  There  is,  however, 
considerable  risk  of  abortion  following  the  operation. 
During  the  first  two  months  of  pregnancy  the  risk  of  abortion 
is  high  (16 — 17  per  cent.),  it  then  decreases  and  remains  com- 
paratively low  until  the  seventh  month,  when  it  again  rises 
and  is  estimated  by  some  observers  as  high  as  20  per  cent,  to 
25  per  cent.  It  follows  that  the  time  for  performing 
ovariotomy  should  be  carefully  chosen,  in  uncomplicated 
cases,  with  a  view  to  diminishing  the  risks  to  the  child. 


FIBROIDS  AND  PREGNANCY  215 

Tumours  of  the  Gravid  Uterus. — I.  Fibroids  and  Preg- 
nancy.— Conception  does  not  readily  occur  in  a  uterus  which 
is  the  seat  of  a  fibroid  tumour  when  that  tumour  is  sub- 
mucous or  interstitial  in  position,  whether  it  is  small  or  large. 
Subperitoneal  fibroids,  however,  are  probably  no  hindrance 
to  conception,  whatever  their  size  may  be.  And  although 
the  first-named  varieties  are  a  hindrance  to  conception  they 


Fig.  85. — Pregnancy  with  Multiple  Fibroid  Tumours  of  the 
Uterus.  The  Placental  Insertion  lies  partly  in  the  Lower 
Uterine  Segment.     (Bland-Sutton.) 

by  no  means  absolutely  prevent  it,  -so  that  the  association  of 
fibroids  with  pregnancy  is  not  uncommonly  met  with. 

The  Diagnosis  of  Pregnancy  in  a  uterus  enlarged  and 
distorted  by  the  presence  of  one  or  more  fibroid  tumours  may 
present  great  difficulties.  The  degree  of  difficulty  will 
depend  in  the  main  upon  the  position  of  the  uterine  cavity 
and  its  relation  to  the  tumour  or  tumours.  Sometimes  the 
cavity  is  anterior  and  accessible  to  abdominal  palpation, 
when  diagnosis  will  be  comparatively  easy  ;  but  it  may  lie 
behind  the  tumour  which  intervenes  between  it  and  the 
abdominal  wall  ;  or,  as  in  Fig.  85,  it  may  be  placed  between 
two  tumours,  when  diagnosis  will  be  very  difficult.     Until 


216  ABNORMAL   PREGNANCY 

the  presence  of  the  foetus  can  be  directly  detected  by  palpa- 
tion, or  by  auscultation  of  the  heart,  the  diagnosis  of  preg- 
nancy can  only  be  presumptive.  During  the  first  five 
months  the  greatest  importance  must  be  attached  to 
amenorrhoea  ;  sudden  cessation  of  the  menses  in  a  patient 
with  a  fibroid  tumour  almost  invariably  implies  pregnancy, 
unless  the  age  of  the  menopause  has  been  reached.  But 
sometimes  irregular  hsemorrhage  takes  the  place  of  amenor- 
rhoea, and  this  change  is  not  so  significant,  as  it  frequently 
occurs  in  connection  with  fibroids  from  other  causes.  Signs 
of  activity  in  the  breasts  carry,  perhaps,  less  than  thek  usual 
importance  in  these  cases,  because  secretion  is  sometimes 
found  in  the  breasts  of  nuUiparous,  non-pregnant  women  who 
are  the  subjects  of  uterine  fibroids.  Pregnancy  causes  rapid 
enlargement  with  softening  of  the  uterus  and,  to  a  less  extent, 
of  the  tumours  which  it  contains.  Owing  to  the  distortion 
caused  by  the  new  growths,  the  alterations  in  shape  charac- 
teristic of  the  early  months  of  pregnancy  cannot  be  made  out, 
while  softening  of  the  cervix  is  usually  late  in  appearing.  A 
uterine  souffle  can  often  be  heard  over  some  part  of  a  non- 
gravid  fibroid  uterus,  so  that  the  presence  of  this  sign  also  is 
unimportant.  It  will  thus  be  readily  seen  that  diagnosis 
must  be  difficult  at  this  stage  of  pregnancy  ;  repeated  exami- 
nations will  be  required,  and  even  then  it  may  be  necessary 
to  postpone  diagnosis  until  the  period  at  which  the  foetal 
heart  can  be  heard. 

During  the  later  months  the  gravid  part  of  the  uterus  may 
be  found  to  occupy  almost  any  position  with  regard  to  the 
tumour  ;  usually  it  is  placed  more  or  less  laterally,  but  may  be 
in  the  upjDcr  or  lower  portions  of  the  mass.  Upon  its  position 
will  depend  the  degree  of  ease  with  which  the  foetal  heart  or 
limbs  can  be  detected. 

Clinical  Course. — Pregnancy  certainly  causes  recognisable 
softening  of  fibroid  tumours,  but  opinions  differ  as  to  whether 
it  causes  their  rate  of  growth  to  increase,  and  the  truth  is  not 
easy  to  establish.  Upon  the  general  course  of  pregnancy  and 
the  development  of  the  foetus,  fibroids  exert  no  unfavourable 
influence,  unless  some  complication  should  arise.  A  fibroid 
tumour  impacted  in  the  pelvis  may  cause  S3vere  pressure 
symptoms  as  the  uterus  develops,  but  these  effects  are  due  to 
the  accident  of  its  position.     Axial  rotation  of  a  stalked  sub- 


FIBROIDS  AND  PREGNANCY  217 

peritoneal  fibroid  may  occur,  though  very  rarely,  during 
pregnancy  ;  and  previously  existing  adhesions  may  become 
troublesome  through  being  stretched.  But  in  the  majority 
of  cases  the  course  of  pregnancy  is  attended  by  very  little 
more  discomfort  than  may  be  met  with  when  there  are  no 
fibroids  present.  There  is,  however,  undoubtedly  a  some- 
what greater  risk  of  pregnancy  ending  prematurely  either  in 
abortion  or  premature  labour.  The  effect  of  fibroids  upon 
labour  will  be  considered  in  a  later  section  (p.  435). 

Management. — Pregnancy  should  be  allowed  to  continue 
until  term,  unless  (1)  severe  complications  due  to  the  tumour 
arise,  or  (2)  the  tumour  is  so  situated  as  inevitably  to  cause 
insuperable  obstruction  during  labour.  In  the  former  case 
the  offending  tumour  should,  if  possible,  be  removed  by 
myomectomy  and  the  uterus  allowed  to  remain.  Even  with 
improved  technique  this  operation  is  attended  with  a  con- 
siderable risk  of  abortion,  for  Devine  has  recently  collected 
130  cases  with  an  abortion  rate  of  23  per  cent.  In  the  latter 
case  there  are  three  possible  alternatives  :  {a)  abortion  may 
be  at  once  induced  ;  (6)  the  pregnancy  may  be  allowed  to 
continue  until  term,  and  the  child  then  delivered  by 
Csesarean  section,  the  uterus  being  at  the  same  time  removed  ; 
(c)  after  extracting  the  child  the  tumour  may  be  enucleated 
and  the  uterus  preserved  (Csesarean  myomectomy).  The 
induction  of  abortion  cannot  be  recommended  ;  the  position 
of  the  fibroid  tumour  necessarily  renders  dilatation  of  the 
cervix  difficult,  and  if  interference  is  necessary  to  evacuate 
the  uterus,  serious  mechanical  obstacles  may  have  to  be  over- 
come. Csesarean  hysterectomy  (see  p.  735)  at  or  near  term 
is  no  more  serious  than  hysterectomy  at  an  earlier  period 
when  the  foetus  is  non-viable,  and  is  therefore  on  the  whole 
the  best  method  of  dealing  with  such  cases.  Csesarean  myo- 
mectomy although  theoretically  preferable  is  actually  a  more 
difficult  and  dangerous  operation  than  hysterectomy,  and  has 
seldom  been  performed. 

II.  Malignant  Uterine  Disease  and  Pregnancy. — Preg- 
nancy is  unknown  in  connection  with  carcinoma  of  the  body 
of  the  uterus  ;  it  may,  however,  be  found  in  association  with 
sarcoma,  and  there  is  reason  to  believe  that  in  some  cases  of 
chorionepithelioma  (deciduoma  malignum)  this  growth  has 
commenced  during  pregnancy.     Cancer  of  the  cervix  and 


218  ABNORMAL   PREGNANCY 

pregnancy  are  not  infrequently  associated  (Fig.  88),  and  the 
diagnosis  does  not  present  the  same  difficulties  as  in  the  case 
of  uterine  fibroids  and  pregnancy  ;  for,  the  body  of  the  uterus 
being  unaffected  by  the  disease,  the  characteristic  changes  in 
it  can  be  recognised  at  any  period  of  pregnancy.  Amenor- 
rhoea  may  be  obscured  by  irregular  haemorrhage  from  the 
growth,  and  of  course  the  condition  of  the  cervix  prohibits  the 
characteristic  softening  of  pregnancy  from  taking  place. 

Management. — When  the  cervical  carcinoma  is  in  the 
operable  stage  the  presence  of  pregnancy  should  be  ignored, 
and  the  whole  uterus  removed  with  the  disease.  The  method 
of  operating  will  depend  upon  the  size  of  the  uterus — i.e.,  the 
stage  of  pregnancy  ;  if  the  child  is  viable  it  can  be  first 
delivered  by  Csesarean  section  ;  if  non-viable  the  uterus  can 
be  removed  by  abdominal  hysterectomy,  the  method  of 
Wertheim  being  the  most  suitable.  When  the  disease  is 
inoperable  abortion  may  be  induced  in  the  early  months  ; 
but  in  advanced  pregnancy  it  is  probably  better  to  wait, 
and  then  dehver  the  child  by  Csesarean  section  at  term. 

Abortion  :    Miscarriage 

Abortion  is  the  expulsion  of  the  ovum  from  the  uterus  at  a 
period  before  the  foetus  has  become  viable  ;  the  term  viable 
signifying  that  the  foetus  is  capable  of  maintaining  its  exis- 
tence when  bom.  Until  the  middle  of  the  seventh  calendar 
month  (twenty-eighth  week)  the  foetus  is  non-viable,  there- 
fore pregnancy  terminating  before  this  date  is  said  to  termi- 
nate by  abortion.  The  term  miscarriage  is  best  employed  as 
a  synonym  of  abortion  ;  sometimes,  however,  the  latter  is 
used  only  during  the  first  two  to  two  and  a-half  months,  when 
the  ovum  possesses  no  properly  developed  placenta,  while  the 
former  is  applied  to  all  stages  of  the  non-viable  period  later 
than  this.  Such  a  distinction  is  confusing  and  has  nothing  to 
commend  it,  because  the  process  is  scarcely  affected  by  the 
presence  or  absence  of  the  placenta.  Abortion  is  a  miniature 
labour  consisting  of  a  stage  of  dilatation,  a  stage  of  expulsion, 
and  a  stage  of  retraction.  It  may  occur  spontaneously  or  be 
intentionally  induced  ;  the  former  alone  will  be  considered 
here,  the  latter  being  dealt  with  among  the  Obstetric 
Operations. 


ABORTION  219 

Causation. — The  causes  of  abortion  are  very  numerous  ; 
they  will  be  best  considered  in  three  groups  :  ( 1 )  pathological 
conditions  of  the  mother  and  of  the  ovum  (including  the 
foetus)  ;   (2)  traumatic  causes  ;  (3)  general  or  systemic  causes. 

( 1 )  The  pathological  conditions,  maternal  and  foetal,  which 
may  cause  abortion  have  been  already  tabulated  (see  p.  107), 
and  the  more  important  ones  fully  considered  as  disorders  of, 
or  associated  with,  pregnancy,  and  need  not  be  again  set  out. 
Of  these  conditions,  some  are  very  apt  to  cause  abortion, 
others  rarely  cause  it  ;  and  from  what  has  been  said  of  each, 
no  difficulty  will  be  experienced  in  distinguishing  between 
those  which  are  important  in  this  respect  and  those  which  are 
not.  A  certain  number  of  cases  may  be  due  to  low  implan- 
tation of  the  ovum  in  the  uterus  {Placenta  prcevia).  After 
the  ovum  has  been  expelled  it  is  impossible  to  demonstrate 
the  position  which  it  occupied,  but  occasional  opportunities 
arise  of  investigating  such  ova  in  situ,  when  the  conditions 
are  seen  to  be  very  favourable  to  the  occurrence  of  abortion. 

(2)  Of  the  traumatic  causes  the  most  important  is  injury 
to  the  uterus  or  the  uterine  contents.  This  may  occur  in  a 
variety  of  ways,  as  from  direct  violence,  such  as  blows  or 
kicks  on  the  abdomen,  or  from  severe  falls  or  other  accidents. 
Sometimes  the  uterus  is  actually  ruptured  by  a  blow  on  the 
abdomen ;  both  blows  and  falls,  however,  usually  operate,  not 
by  injuring  the  uterus,  but  by  causing  detachment  of  some 
part  of  the  ovum  from  the  uterine  wall.  Abortion  may  be 
brought  about  by  passing  the  sound  or  some  other  instrument 
into  the  uterine  cavity,  either  inadvertently,  or  with  the 
intention  of  setting  up  a  miscarriage.  Sometimes,  however, 
the  passing  of  the  sound  into  the  uterus  does  not  produce  this 
effect.  Unless  some  definite  injury  is  caused  to  the  ovum, 
such  as  rupture  of  the  chorionic  sac,  or  partial  detachment, 
no  harm  follows  ;  there  is  no  doubt  that  the  sound  may  be 
passed  into  the  decidual  cavity  without  injuring  the  ovum  at 
all.  If  infection  is  carried  into  the  uterus  by  dirty  instru- 
ments abortion  may  be  brought  about  by  septic  endometritis. 
Operations  upon  the  gravid  uterus  or  the  uterine  appendages 
are  frequently,  though  by  no  means  invariably,  followed  by 
abortion,  which  in  this  case  probably  results  from  disturbance 
of  the  uterine  or  pelvic  circulation.  Injury  to  the  ovum  does 
not  necessarily  produce  abortion  immediately,  an  interval  of 


220  ABNORMAL   PREGNANCY 

several  days,  or  even  a  week  or  two,  elapsing  before  abortion 
sets  in. 

Next  in  importance  to  direct  or  indirect  injury  must  be 
placed  a  group  of  conditions  which  cause  abortion  by  exciting 
the  uterine  centre  situated  in  the  lumbar  enlargement  of  the 
spinal  cord  (see  p.  278),  the  stimulus  being  conveyed  through 
the  central  nervous  system.  Extreme,  degrees  of  grief  or 
fright,  as  from  sudden  bereavement  or  personal  danger,  may 
cause  abortion,  especially  in  women  of  nervous  temperament ; 
and  it  is  clear  that  such  conditions  can  only  operate  in  the 
manner  just  indicated.  Over-fatigue,  especially  from  dancing 
and  riding,  probably  acts  in  the  same  way.  Operations  upon 
distant  parts  performed  during  pregnancy  also  sometimes 
induce  abortion,  which  must  clearly  be  produced  through  the 
central  nervous  system.  These  conditions,  all  of  which 
involve  '  shock  '  to  important  nerve-centres,  may  be  justly 
classed  as  traumatic. 

Many  drugs  have  from  time  to  time  been  employed  for  the 
iUicit  production  of  abortion  (abortifacients),  but  no  scientific 
study  of  their  mode  of  action  has  ever  been  made.  The 
greater  number  of  them  are  irritant  poisons. 

(3)  The  general  or  systemic  causes  consist  of  a  number  of 
concUtions,  the  action  of  which  in  causing  abortion  is  imper- 
fectly understood.  Thus  consanguinity  of  the  parents,  liigh 
altitude,  and  hot  chmate  are  all  beheved  to  cause  it.  Un- 
healthy occupations  pursued  by  the  mother  alone  or  by  both 
parents,  such  as  working  ^\ii.\\  lead,  mercury,  or  glass, 
undoubtedly  also  cause  abortion.  Habitual  over-indulgence 
in  alcohol,  and  excessive  sexual  intercourse,  are  said  to  favour 
its  occurrence. 

Of  all  the  systemic  causes  of  abortion,  however,  the  most 
important  in  all  respects  is  syphilis.  In  all  probabihtj^  more 
abortions  are  due  to  this  disease  than  to  any  other  cause.  In 
cases  of  repeated  abortion  the  probabihty  of  a  paternal 
syphilitic  taint  is  very  high,  and  the  Wassermann  test  must 
be  applied  to  both  parents.  The  manner  in  which  constitu- 
tional syphihs  produces  abortion  is  not  kno^^^l;  in  many 
cases,  chnically  sj^hihtic,  no  morbid  changes  can  be  found 
in  chorion  or  decidua  after  its  discharge.  Investigations  are 
now  being  undertaken  to  determine  whether  the  specific 
organism  can  always  be  detected  in  such  cases  ;  its  presence 


ABORTION  221 

in  large  numbers  would  indicate  fcetal  bacterial  toxaemia  as 
the  cause  of  the  abortion .  Men  who  have  suffered  from  the 
disease,  but  in  whom  syphihtic  lesions  are  no  longer  clinically 
recognisable,  may  either  beget  children  definitely  syphilitic, 
or  the  development  of  the  ovum  may  be  brought  to  an  early 
termination  by  abortion.  It  is  therefore  clear  that  the 
infective  agent  must  be  transmitted  in  some  form  to  the 
developing  ovum. 

It  must  be  added  that  the  cause  of  abortion  in  a  particular 
case  is  often  very  difficult  to  trace  ;  and  in  exceptional  cases 
an  apparently  healthy  patient  may  have  a  series  of  abortions 
for  which  no  adequate  explanation  can  be  discovered.  When 
syphilitic  infection,  associated  disorders,  and  traumatic 
causes  of  abortion  can  be  excluded,  the  most  probable  cause 
is  an  unhealthy  condition  of  the  endometrium  upon  which 
the  ovum  was  embedded,  and  to  this  condition  a  series  of 
abortions  may  be  due. 

Frequency. — It  will  be  clear  from  this  enumeration  of  the 
conditions  which  cause  it  that  abortion  is  not  an  uncommon 
event.  From  some  recent  statistics  presented  by  Professor 
Malins  to  the  Obstetrical  Society  of  London  it  appears  that  in 
this  country  about  16  per  cent,  of  pregnancies  terminate  by 
abortion — i.e.,  one  abortion  occurs  to  every  five  births  of 
viable  children  ;  and  further  it  appears  that  abortion  is 
nearly  twice  as  frequent  among  the  classes  from  which 
hospital  patients  are  drawn  as  among  the  well-to-do. 
Presented  in  another  way,  it  may  be  said  that  from  30  per 
cent,  to  40  per  cent,  of  all  fertile  women  pass  through  one  or 
more  abortions  during  the  period  of  child-bearing.  Far 
more  abortions  occur  in  the  third  month  of  pregnancy  than 
in  any  other  month.  Women  who  are  the  subjects  of  syphilis 
or  Bright's  disease  often  sustain  a  succession  of  abortions 
without  carrying  any  pregnancy  to  term. 

Clinical  Features. — The  symptoms  which  accompany  the 
process  of  abortion  are  hcemorrhage  and  pain .  Haemorrhage 
is  almost  invariably  the  initial  symptom,  and  is  caused  by 
separation  of  the  ovum  or  of  some  part  of  the  decidua  from 
the  uterine  wall  (Fig.  86).  The  bleeding  is  usually  slight  at 
first,  but  as  the  abortion  proceeds  it  may  become  profuse, 
and  dangerous,  or  even  fatal  in  its  severity.  Clots  form  in 
the  vagina,    and   more   rarely   in   the   uterus   itself,   when 


222 


ABNORMAL   PREGNANCY 


N  on  -  separated 
centa 


i   C' 


bleeding  is  free.  A  young  ovum  of  six  to  ten  weeks  with  its 
membranes  may  be  discharged  either  entire  or  piecemeal 
along  with  these  clots  and  thus  be  overlooked.  Pain  is 
usually  intermittent,  and  is  due  to  uterine  contractions. 
Sometimes  it  is  continuous,  and  the  uterus  when  examined 
may  be  hard  and  unchanging  in  consistence  ;  at  other  times 
the  whole  process  may  be  attended  with  httle  or  no  pain. 

After  the  discharge  of 
the  ovum  from  the 
uterus  the  pain  ceases. 
On  vaginal  ex- 
amination dilatation  of 
the  internal  os  can 
usually  be  recognised 
soon  after  the  onset  of 
these  symptoms.  The 
student  must  recollect 
that  in  a  multipara 
the  external  os  is 
often  patulous  under 
ordinary  conditions, 
allowing  of  the  intro- 
duction of  the  finger- 
tip into  the  cervical 
canal  ;  but  the  inter- 
nal OS  is  never  opened 
early  in  pregnancy 
except  by  active  con- 
tractions. In  the  di- 
latilig  cervical  canal  the  finger  will  often  feel  a  soft,  somewhat 
bulging  swelling,  which  may  be  a  clot  of  blood,  or  the  lower 
pole  of  the  ovum  detached  from  the  uterine  wall  and  lying 
free  in  the  lower  part  of  the  uterine  cavity  and  cervix  (Fig. 
87).  Sometimes  dilatation  of  the  cervix  proceeds  irregu- 
larly, the  external  os  opening  last  after  the  internal  os  has 
been  abeady  fully  dilated  ;  this  offers  some  difficulties  in 
diagnosis,  for  the  condition  of  the  cervix  within  the  external 
OS  cannot  well  be  recognised. 

When  the  cervical  canal  is  sufficiently  dilated,  the  ovum 
is  expelled  through  it  by  the  uterme  contractions,  either 
entire  or  in  pieces  ;   an  early  ovum  discharged  in  pieces  may 


Closed  cervical 
canal 


Fig.  86. — Abortion  :  Stage  I.     Ovum  par- 
tially detaclied,  Cervix  closed.     (Edgar.) 


ABORTION 


223 


Blood  clots 


Blood 
clot 


escape  notice  unless  all  the  blood  and  blood-clot  passed  by 
the  patient  is  carefully  examined.  The  uterus  rapidly 
retracts  and  the  cervix  closes  down,  so  that  in  a  few  hours 
no  trace  of  dilatation  can  be  detected,  and  the  con- 
sistence of  the  uterine  body  is  firm.  For  several  days  a 
hsemorrhagic  discharge  occurs,  similar  to  the  lochial  discharge 
of  the  puerperium, 
and  the  uterus  itself 
undergoes  a  process 
of  involution  similar 
to  puerperal  involu- 
tion. If  a  portion 
of  the  ovum  or  de- 
cidua  remains  un- 
expelled  from  the 
uterus,  the  haemor- 
rhage will  continue 
until  it  has  been  got 
rid  of  and  involu- 
tion will  be  arrested. 

A  number  of 
terms  are  in  com- 
mon use  in  this 
country  which  are 
intended  to  de- 
scribe certain  clini- 
cal varieties  or 
phases  of  the  pro- 
cess of  abortion  ; 
thus    we    speak    of 

threatened  abortion,  inevitable  abortion,  incomplete  abortion, 
and  missed  abortion. 

Threatened  Abortion. — Sometimes  pain  and  haemorrhage 
occur  during  early  pregnancy,  without  leading  to  dilatation 
of  the  cervix.  Caution  must  be  exercised  in  attributing 
these  symptoms  in  all  cases  to  threatened  abortion,  for  they 
may  result  from  a  number  of  other  causes — e.g.,  the  bleeding 
may  not  come  from  the  body  of  the  uterus  at  all,  but  from 
some  concurrent  disease  of  the  cervix,  such  as  a  polypus  or  a 
malignant  growth.  And  when  the  bleeding  can  be  clearly 
traced  to  the  uterine  cavity,  abortion  by  no  means  always 


__  Dilating 
cervical  canal 


Fig.  87. — Abortion  :  Stage  II.  Ovum  almost 
completely  detached, Cervix  dilated, Lower 
Pole  of  Ovum  protruding.     (Edgar.) 


224 


ABNORMAL  PREGNANCY 


ensues  :    it  is  certain  that  a  good  deal  of  hgemorrhage  may 
occur  in  early  pregnancy  without  causing  detachment  of  the 


Decidua  capsularis 


Placenta. 


■//'  Haeraorrh.age 
into  decidua,! 
space 


intem-LLm 


Os  externum 


Carcinomatous  grow-fch^^^v/,^ 


in  cervix 


Fig.  88. — Grravid  Uterus  (Foui'th  Month),  showing  extensive  Decidual 
Haemorrhage  without  Detachment  of  the  Ovum.  (Charing  Cross 
Hospital  Museum.) 

The  uterus  was  removed  for  carcinoma  of  the  cervix. 

ovum.     For   example,    haemorrhage    may    occur   from   the 
lindetached  decidua  in  decidual  endometritis,   or  in  con- 


ABORTION  225 

nection  with  cardiac  or  hepatic  disease  of  the  mother.  It  is 
even  possible  that  sHght  detachment  of  some  part  of  the 
ovum  or  the  decidua  itself  may  be  repaired  and  the  gestation 
allowed  to  continue.  In  Fig.  88  it  is  seen  that  considerable 
hsemorrhage  has  occurred  into  the  decidual  space  without 
separation  of  the  ovum,  which  is  intact,  though  somewhat 
compressed.  Clinically,  the  bleeding  in  this  case  was  attri- 
buted to  the  coincident  malignant  disease  of  the  cervix. 
Whatever  may  be  the  explanation,  it  is  certain  from  clinical 
experience  that  one  or  more  smart  haemorrhages  in  early 
pregnancy,  or  slight  bleeding  continued  for  several  weeks,  is 
not  incompatible  with  the  completion  of  gestation  and  the 
birth  of  a  healthy  child.  Pain  and  haemorrhage  must  there- 
fore never  be  regarded  as  certain  indications  of  abortion 
unless  they  are  accompanied  by  dilatation  of  the  internal 
OS,  or  the  expulsion  of  some  part  of  the  ovum  (foetal  or 
maternal)  ;  when  unaccompanied  by  these  changes  it  is 
convenient  to  refer  to  the  condition  as  threatened  abortion. 
By  suitable  treatment  the  process  can  often  be  arrested  here 
and  the  danger  averted.  It  is  not  uncommon,  however,  for 
symptoms  of  threatened  abortion  to  subside,  and  after  an 
interval  to  recur  with  greater  severity.  The  condition  must, 
however,  always  be  regarded  seriously,  for  alarming  and 
even  fatal  haemorrhage  may  occur  from  separation  of  an 
early  ovum  without  any  attempt  being  made  by  the  uterus 
to  evacuate  its  contents  spontaneously.  Such  cases,  being 
unattended  by  dilatation  of  the  cervix,  are  technically  cases 
of  threatened  abortion. 

Inevitable  Abortion. — When  the  pains  are  regular  and 
intermittent,  when  the  internal  os  commences  to  open,  when 
the  ovum  has  been  detached  and  can  be  felt  in  the  cervix, 
or  when  some  portion  of  the  decidua  has  been  expelled,  the 
process  of  abortion  cannot  be  arrested,  and  is  therefore  said 
to  be  inevitable.  It  is  not  in  all  cases  easy  to  say  whether  or 
not  an  abortion  is  inevitable,  unless  the  finger  can  be  passed 
up  to  the  internal  os,  or  unless  some  parts  of  the  ovum  has 
been  discharged  and  recognised.  Sometimes,  however,  it  is 
possible  to  recognise  uterine  contractions  by  palpation,  and 
this  forms  a  useful  sign,  for  in  threatened  abortion  the  uterus 
does  not  contract  sufficiently  to  be  recognisable  by  palpation. 
During  a  contraction,  the  uterus  becomes  uniformly  hard  in 
E.M,  15 


226 


ABNORMAL  PREGNANCY 


consistence,  and  often  a  Kttle  irregular  in  shape  ;  the  con- 
traction may  be  very  prolonged,  lasting  for  several  minutes. 
In  the  early  stages  this  sign  is  sometimes  useful  in 
diagnosis,  but  eventually  dilatation  of  the  cervix  is  the 
change  upon  which  the  recognition  of  an  inevitable  abortion 
depends.     The  distinction  between  threatened  and  inevitable 


Decidua 


Ovxxax 
attcbcKed  to 
Mood    clot 


Fig.  89. — Two  to  Three  Weeks'  Abortion.  The  Chorionic  Sac 
is  partially  covered  with  A'illi,  and  has  become  attached 
to  a  piece  of  Blood  Clot. 


abortion  is  an  important  practical  point,  for  the  two  phases 
must  be  differently  treated. 

Incomplete  Abortion. — This  name  imphes  that  some  por- 
tion of  the  placenta  or  of  the  decidua  has  been  retained  in 
the  uterus  ;  the  condition  is  also  often  termed  '  retention  of 
products  of  concej)tion.'  Continuance  of  bleeding,  with 
absence  of  the  expected  involution  of  the  uterus,  are  the  chief 
symptoms  ;  to  these  may  be  added  those  of  septic  infection, 
if  the  cavity  of  the  uterus  has  not  been  kept  sterile. 

Missed  Abortion. — This  term  has  already  been  ex- 
plained when  describing  the  fleshy  or  cameous  mole  (p.  148). 


ABORTION 


227 


Symptoms  of  threatened  abortion  occur,  which  subside,  and 
after  a  variable  period  a  mole  is  expelled. 

Anatomy  of  Abortion. — The  condition  of  the  ovum  when 


Chorion,  with 
vilh 


AmniorL  conbainin-g- 
foetus 


Fig.  90. — Six  Weeks'  Abortion.  Tlie  Ovum  has  escaped  from  the  Decidua 
Capsularis,  the  Chorion  has  ruptured,  the  Amnion  is  entire. 
(Charing  Cross  Hospital  Museum.) 

expelled  depends  partly  upon  its  period  of  gestation,  and 
partly  upon  the  changes  which  it  has  previously  undergone. 
The  great  majority  of  aborted  ova  show  no  recognisable 
morbid  change  ;    they  were  apparently  healthy  up  to  the 

15—2 


228  ABNORMAL   PREGNANCY 

time  of  their  expulsion.  Others  show  various  stages  of  the 
blood-mole  previously  described,  or  of  the  hydatidiform  mole, 
these,  of  course,  being  ova  of  the  first  three  months  of  gesta- 
tion. Older  ova  which  possess  a  defuiite  placenta,  when 
retained  for  some  weeks  after  the  death  of  the  foetus,  show 
well-defined  post-mortem  changes,  including  those  already 
described  as  placental  infarcts.  In  some  cases  infection  has 
occurred  previous  to  the  abortion,  and  the  tissues  of  the 
ovum  maj^  then  be  expelled  in  a  state  of  decomposition  and 
having  an  offensive  odour. 

Ova  apparently  healthy  may  be  expelled  entire — vrith.  or 
without  the  maternal  coverings — or  piecemeal.  During  the 
first  and  second  months  the  ovum,  when  thro^^^i  off,  may 
c&rry  with  it  all  the  decidual  coverings,  the  whole  contents 
of  the  uterus  being  thus  evacuated  en  bloc.  More  frequently 
the  decidua  capsularis  is  ruptured,  and  the  ovum  (chorioii, 
amnion,  and  foetus)  escapes  and  is  expelled  entire  through 
the  cervix  (Figs.  89  and  90).  The  attachments  of  the  chorion 
to  the  decidua  are  so  delicate  at  this  period  that  the  force 
of  the  uterine  contractions  alone  severs  them  completely. 
After  the  second  month  the  chorion  as  well  as  the  decidua  is 
usually  ruptured  (Fig.  91)  ;  the  amnion,  being  more  elastic, 
usually  resists,  but  it  also  may  be  ruptured,  and  then  the 
foetus  escapes  and  may  be  lost  in  the  discharged  blood. 
Often  the  chorion  and  decidua  are  so  firmly  attached  to  one 
another  and  to  the  uterus  that  a  portion  of  chorion  remains, 
making  the  abortion  incomplete  :  this  is  more  apt  to  occur 
with  the  placental  chorion  than  with  the  chorion  Iseve. 

The  period  of  gestation  to  which  the  ovum  belongs  may 
be  estimated  from  the  size  and  characters  of  the  foetus,  or 
from  the  size  of  the  chorionic  sac  when  entire.  The  size  and 
characters  of  the  foetus  at  different  periods  of  development 
have  been  stated  on  p.  57  ;  they  form  the  best  guide  to  the 
period  of  development  of  the  ovum.  When  the  foetus  has 
been  lost  other  criteria  must  be  relied  upon.  The  size  of  the 
unruptured  chorionic  sac  is  the  next  best  guide  ;  during 
the  first  three  months  it  is  as  follows  ■ 

4tli  week     .         .         .     about  1     X    |  of  an  inch  (2-5   X    2  cm.). 

Sth ,,      2    X  If  inches         (  5     x    4  cm.). 

12th ,,      Ux-ii      „  flUxllJcm.). 

Up  to  the  eighth  or  ninth  week  the  whole  chorion  is 


ABORTION 


229 


covered  with  villi  (Fig.  91)  ;  then  those  of  the  chorion  Iseve 
atrophy,  and  by  the  end  of  the  third  month  the  discoidal 
placenta  has  been  definitely  outlined.  It  seldom  happens 
that  a  foetus  of  the  size  of  three  months'  development 
escapes  recognition  in  a  miscarriage. 

Differential  Diagnosis. — Two  other  conditions  resemble 


Eio.  91. — Two  and  a  Half  Months'  Abortion.    (Charing  Cross 
Hospital  Museum.) 

abortion  inasmuch  as  they  are  characterised  by  the  expulsion 
of  a  body  from  the  uterus  with  haemorrhage  and  pain  :  they 
are  (1)  tubal  gestation  and  (2)  an  intra-uterine  polypus. 

(1)  The  former  has  already  been  referred  to  (p.  193). 
It  has  been  pointed  out  that  the  structure  of  the  decidual 
membrane  is  identical  in  both  uterine  and  extra-uterine 
pregnancy,  and  therefore  uterine  abortion  cannot  be  diag- 
nosed unless  structures  recognisable  as  chorionic  or  fcetal 


230  ABNORMAL  PREGNANCY 

have  been  expelled  from  the  uterus.  (2)  An  intra-uterine 
polypus  sometimes  protrudes  through  the  cervix,  either 
with  or  mthout  complete  detachment.  Haemorrhage,  pain, 
enlargement  of  the  uterus,  dilatation  of  the  mtemal  os,  and 
the  presence  of  a  soft  bulging  swelling  in  the  cervical  canal 
may  appear  to  justify  a  diagnosis  of  inevitable  abortion. 
But  further  inquiry  and  examination  will  serve  to  dis- 
tinguish the  two,  for  with  a  polypus  there  will  be  a  history 
of  haemorrhage,  not  amenorrhoea,  and  the  customary  signs 
and  symptoms  of  pregnancy  will  be  absent. 

It  must  also  be  borne  in  mind  that  during  menstruation 
the  uterus  undergoes  changes  similar  to  those  found  at  the 
beginning  of  an  abortion,  i.e.,  the  uterine  body  is  softened, 
and  the  cervix  undergoes  slight  dilatation.  In  the  case  of 
women  who  menstruate  irregularly,  the  occurrence  of  bleed- 
ing after  a  prolonged  interval  may  be  regarded  as  an  abor- 
tion unless  attention  is  paid  to  the  points  just  mentioned. 
During  a  menstrual  period  no  membrane  is  discharged 
except  in  the  rare  cases  of  "membranous  dysmenorrhoea," 
and  in  these  cases  the  membrane  can  be  distinguished  bj^ 
microscopic  examination  from  the  decidua  of  pregnancy. 

Treatment. — Prophylactic  treatment  is  naturally  of 
great  importance.  Many  of  the  conditions  described  as 
systemic  causes  of  abortion  are  capable  of  being  cured  by 
appropriate  treatment.  Syphihs  is  perhaps  the  most  impor- 
tant of  these,  and  the  necessity  of  treating  both  parents  in 
such  cases  has  been  already  mentioned.  The  biological 
blood  test  introduced  by  Wassermann  will  enable  a  diagnosis 
of  this  condition  to  be  made  whenever  it  exists  in  either 
parent.  Careful  management  of  pregnancy  in  the  early 
months  may  obviate  certain  of  the  traumatic  causes  ;  and 
it  is  a  popular  behef,  which  is  supported  to  some  extent  by 
chnical  experience,  that  the  menstrual  epochs  are  times  of 
greater  danger,  when  unusual  precautions  are  required.  In 
cases  of  decidual  endometritis  and  of  repeated  abortion  for 
which  no  systemic  or  local  cause  can  be  found,  curettage 
of  the  uterus  is  useful.  If  the  least  suspicion  of  syphihtic 
taint  exists  in  such  cases,  specific  treatment  should  also  be 
fully  carried  out. 

An  important  point  in  prophylaxis  is  that  local  examina- 
tion of  the  uterus  during  the  first  three  months  should  be 


ABORTION  231 

conducted  with  great  care  and  gentleness,  and  should  not 
be  repeated  unnecessarily.  In  cases  of  backward  displace- 
ment unaccompanied  by  symptoms,  abortion  has  frequently 
been  caused  by  attempts  to  replace  the  uterus  ;  replace- 
ment, it  will  be  recollected,  is  unnecessary  until  definite 
symptoms  supervene,  and  should,  therefore,  be  avoided. 

In  threatened  abortion  the  object  of  treatment  is  to 
arrest  the  process  ;  in  inevitable  abortion  the  object  is  to 
assist  it. 

Threatened  abortion  is  accordingly  treated  by  confining 
the  patient  strictly  to  bed,  by  avoiding  as  far  as  possible  all 
forms  of  exertion  and  excitement,  and  by  the  administration 
of  sedatives.  No  local  treatment  should  be  adopted.  After 
the  first  examination  from  which  it  has  been  recognised  that 
the  abortion  is  not  inevitable,  no  further  vaginal  examination 
should  be  made  unless  the  case  proceeds  unfavourably.  The 
diet  should  be  kept  low  and  no  alcohol  given  ;  the  bowels  not 
allowed  to  become  confined.  Various  sedative  drugs  may  be 
administered,  some  of  which  are  general,  others  special  in 
their  action.  The  most  generally  useful  drug  is  opium,  and 
the  treatment  may  be  commenced  with  a  hypodermic  injec- 
tion of  a  quarter  of  a  grain  of  morphia,  and  the  action  of  the 
drug  maintained  for  two  or  three  days  by  small  repeated 
doses  of  opium  pill  or  laudanum.  Bromide  of  potassium 
and  chloral  hydrate  are  useful  in  patients  of  excitable  tem- 
perament. Certain  drugs  are  believed  to  exert  a  specific 
sedative  effect  upon  the  uterus  ;  among  them  may  be  men- 
tioned viburnum,  cannabis  indica,  and  ergot  in  small  doses  ; 
it  must,  however,  be  admitted  that  the  evidence  of  such  an 
effect  is  unsatisfactory.  After  a  threatened  abortion  the 
patient  should  be  kept  in  bed  for  at  least  a  week  after  all 
bleeding  has  ceased.  If  the  symptoms  recur  the  same  rule 
must  be  strictly  followed. 

A  case  of  threatened  abortion  may  at  any  time  become 
inevitable,  requiring  a  prompt  change  of  treatment.  In  any 
case  where  the  amount  of  bleeding  is  sufficiently  profuse 
seriously  to  affect  the  patient's  condition,  the  treatment  of 
inevitable  abortion  must  be  adopted,  even  if  there  is  no 
dilatation  of  the  cervix. 

Inevitable  Abortion. — In  many  cases  this  process  will  pro- 
ceed naturally,  and  terminate  without  any  interference  on 


232 


ABNORMAL   PREGNANCY 


the  part  of  the  medical  practitioner,  and  with  a  perfectly 
favourable  result.  Under  such  circumstances  nothing  is 
required  beyond  the  administration  of  ergot  in  full  doses  (one 
drachm  of  liquid  extract,  or  3  gr.  of  ergotine  every  four  hours), 
which  is  useful  in  stimulating  the  uterus,  preventing  retention 
of  fragments  of  the  decidua  or  ovum,  and  ensuring  proper 
retraction  afterwards. 

In  conducting  even  the  simplest  case  of  inevitable 
abortion  two  points  are  of  the  greatest  importance.  Firstly, 
all  blood-clot  and  blood-stained  coverings  must  be  carefully 
examined,  as  the  uterine  contents  may  be  discharged  piece- 
meal ;  the  nurse  must  accordingly  be  instructed  to  save 
everything  for  the  inspection   of   the   medical   attendant. 


Fig.  92. — Sims'  Speculum. 

Secondly,  the  strictest  antiseptic  precautions  must  be 
observed  throughout. 

It  must  be  understood  that  the  management  of  an  abor- 
tion calls  for  the  greatest  possible  care  in  the  prevention  of 
infection,  and  the  antiseptic  routine  to  be  described  later  on 
for  the  management  of  normal  labour  (see  p.  308)  must  be 
applied  just  as  thoroughly  and  conscientiously  to  a  case  of 
abortion.  The  results  of  infection  may  be  quite  as  serious  or 
even  as  disastrous  as  those  of  ordinary  puerperal  infection. 

Interference  during  the  course  of  an  inevitable  abortion 
may  become  necessary  from  excessive  hsemorrhage,  from 
lise  of  temperature,  or  from  inabihty  of  the  uterus  completely 
to  expel  its  contents  (incomplete  abortion).  Hcemorrhage  may 
become  profuse  or  even  dangerous  at  any  stage  of  the  pro- 
cess ;  it  is  of  course  due  in  the  early  stages  to  the  separation 
of  the  ovum  from  the  uterine    wall    and  the  consequent 


ABORTION 


233 


rupture  of  maternal  vessels.  The  haemorrhage  abates  to  some 
extent  when  the  ovum  has  been  completely  separated,  even 
when  it  is  not  yet  expelled  from  the  uterine  cavity  ;  but 
while  any  portion  remains  un detached  it  will  continue. 
Rise  of  temperature  during  a  miscarriage  necessarily  arouses 
suspicion  of  infection,  and  is  always  to  be  regarded  as  an 
indication  for  terminating  the  process  by  immediate  evacua- 
tion of  the  uterus  in  the  manner  described  below.  Finally, 
from  slow  dilatation  of  the  cervix,  from  morbid  adhesion  of 
some  part  of  the  ovum,  or  from  weak  contractions  the  abortion 
may  be  so  much  delayed  as  to  require  interference.  In 
abortion  occurring  during  the  first  two  months  there  is  con- 
siderable risk  of  retention  of  a  portion  or  even  of  the  whole 
of  the   decidua.     Unless   the  whole   of   this   membrane  is 


Fig.  93. — Fenton's  Uterine  Dilator. 


found  in  the  discharges,  the  case  should  be  treated  as  an 
incomplete  abortion  in  the  manner  described  below.  Re- 
tained decidua  is  a  fertile  source  of  haemorrhage,  and  also 
predisposes  to  septic  infection. 

Whenever  surgical  interference  is  required  to  terminate 
a  miscarriage  the  method  adopted  should  be  the  same, 
viz.,  immediate  evacuation  of  the  uterus  under  anaesthesia. 
In  former  editions  of  this  work  vaginal  and  cervical  plugging 
(tamponade)  was  recommended  when  the  cervix  was  not 
sufficiently  dilated  to  admit  of  the  passage  of  the  foetus  and 
placenta.  Increasing  experience  of  this  method  has  shown 
that  certain  disadvantages  which  are  inseparable  from  it  far 
outweigh  its  advantages.  These  are  (1)  that  it  cannot  be 
carried  out  with  efficient  asepsis,  and  while  in  the  vagina  the 
plug  is  liable  to  become  infected  ;    (2)  the  method  is  slow 


234 


ABNORI^IAL   PREGNANCY 


and  uncertain,  and  frequently  ends  in  incomplete  evacuation 
of  the  contents,  so  that  an  operation  becomes  necessary  after 
all ;  on  the  other  hand  the  method  of  immediate  evacuation 


i 


Fig.  94. — Separation  of  the  Bladder  from  the  fr-ont  of  the  Cervix 
to  the  level  of  the  Utero- vesical  Pouch. 


is  easy,  rapid  and  certain,  and  can  be  carried  out  under 
efficient  asepsis.  Vaginal  plugging  should  therefore  not  be 
done  unless  operative  measures  are  impracticable. 

Immediate  Evacuation  of  the  Uterus. — ^Under  anaesthesia 
the  cervix  is  first  exposed  with  a  speculum  such  as  that  of 


ABORTION 


235 


Sims,  and  then  seized  with  volsellum  forceps.  The  vaginal 
walls  and  cervix  are  next  swabbed  with  tincture  of  iodine. 
Rapid  dilatation  may  be  performed  by  means  of  graduated 
metal  cervical  dilators  (Fig.  93)  until  the  index  finger  can  be 
introduced  easily  into  the  uterus.  This  will  allow  sufficient 
room  to  remove  a  two  and  a  half  months'  miscarriage;  for 
cases  more  advanced  than  this  incision  of  the  cervix  may 
be  practised  as  in  vaginal  Csesarean  section  (Fig.  94).  The 
uterine  body  should  then  be  gently  pressed  down  with  one 
hand  above  the  pubes,  until  the  finger  in  the  cervix  can  be 
worked  thoroughly  into  the  cavity.  The  ovum  must  next 
be  completely  detached  with  the  finger-tip,  special  attention 
being  paid  to  the  uterine  angles.  The  finger  should  then  be 
removed  from  the  uterus,  and  by  compressing  the  uterine 
body  between  the  external  hand  and  two  fingers  in  the 


Fig.  95. — Ovum  Forceps. 


vagina,  the  whole  contents  may  be  squeezed  out.  If  this 
should  not  succeed,  a  pair  of  blunt  ovum  forceps  (Fig.  95) 
may  be  passed  into   the   uterus  and  the  ovum  removed 

gently. 

It  is  difficult  to  detach  the  decidual  membrane  with  the 
finger,  and  a  sharp  flushing  curette  should  be  next  employed 
to  detach  and  remove  it.  The  curette  must  be  used  with 
gentleness,  and  the  whole  uterine  wall  scraped  from  above 
downwards  ;  large  pieces  of  thick  membrane  will  thus  be 
removed.  The  finger  should  then  be  passed  again  to  make 
sure  that  the  uterus  has  been  completely  emptied.  Next 
the  empty  uterus  is  massaged  firmly  between  two  or  three 
fingers  passed  into  the  vagina  and  the  other  hand  placed 
above  the  pubes,  and  to  do  this  properly  the  organ  should  be 
first  anteverted.  This  squeezes  out  blood  and  promotes 
uterine  retraction,  thus  arresting  haemorrhage. 


236  ABNORMAL  PREGNANCY 

Finally,  both  the  uterus  and  vagina  should  be  carefully 
douched  with  a  hot  antiseptic  solution,  such  as  lysol,  a 
drachm  to  a  quart  (temperature  120°  Fahr.),  and  the  vagina 
loosely  plugged  with  iodoform  gauze.  The  strictest  antiseptic 
precautions  are  called  for  in  performing  this  simple  operation ; 
the  vulva  should  be  shaved  and  swabbed  with  tincture  of 
iodine,  the  vaginal  walls  swabbed  with  it  also,  and  sterilised 
rubber  gloves  should  be  used  by  the  operator. 

Septic  Abortion. — Evacuation  of  the  uterus  by  this  method 
should  be  practically  devoid  of  risk  under  ordinary  condi- 
tions. Occasionally,  however,  cases  come  first  under  treat- 
ment after  acute  septic  infection  has  occurred,  and  the  whole 
or  a  part  of  the  ovum  is  still  in  the  uterus.  The  greater 
number  of  such  cases  are  the  work  of  criminal  abortionists. 
The  process  of  clearing  out  the  uterus  is  then  attended  by 
considerable  danger,  for  in  detaching  the  placenta  or  mem- 
branes blood  vessels  are  laid  open  into  which  infective 
material  may  find  direct  access  during  the  operation.  In  this 
way  the  generahsation  of  the  infective  process  is  actually 
assisted.  Nevertheless  it  is  sound  practice  to  follow  the 
surgical  rule  that  actively  infected  cavities  must  always  be 
cleared  of  their  contents  and  freely  drained.  In  performing 
the  operation  under  these  conditions  cutting  or  sharp 
scraping  instruments  should  be  avoided,  and  the  uterus 
cleared  out  with  the  finger  alone  or  aided  only  by  a  blunt 
curette.  A  septic  uterus  also  should  never  be  plugged,  as  free 
drainage  is  essential. 

The  after-treatment  of  abortion  is  conducted  upon  the 
same  principles  as  the  normal  puerperium  (p.  542).  Women 
of  the  poorer  classes  often  pay  little  or  no  attention  to  a 
miscarriage  ;  they  do  not  seek  medical  advice,  nor  do  they 
consider  that  a  subsequent  period  of  rest  is  necessary.  But 
many  forms  of  chronic  pelvic  inflammation  arise  from  a 
neglected  miscarriage,  and  it  is  the  medical  man's  duty  to 
enforce  proper  management  and  an  adequate  period — at 
least  ten  days — of  rest  in  bed. 

Death  and  Retention  of  the  Foetus  in  Utero 

When  an  ovum  perishes  in  utero  during  the  first  three 
or  four  months  of  pregnancy,  the  cause  is  usually  to  be  found 


DEAD    OVUM 


237 


in  the  changes  described  in  connection  with  fleshy  or 
hydatidiform  moles.  At  a  later  period  it  is  not  infrequent 
for  the  foetus  to  perish  in  utero  from  various  causes  which  do 


Fig.  96. — A   Complete  Ovum  of  Three  Months'  Development,  retained 
for  some  weeks  after  death.     (Charing  Cross  Hospital  Museum.) 

An  opening  has  been  made  in  the  chorion  to  sliow  the  foetus  in  the  amniotic  sac. 

not  lead  to  the  production  of  gross  anatomical  changes  in  the 
placenta  or  membranes  (Fig.  96).  In  cases  of  acute  infection 
from  the  maternal  blood, '  as  may  occur,  for  example,  m 
typhoid  fever,  the  ovum  is  usually  expelled  at  once.  In  other 
cases  the  ovum  may  be  retained  in  utero  for  many  weeks 


238  ABNORMAL   PREGNANCY 

before  being  expelled,  and  it  then  undergoes  a  series  of 
well-defined  changes  which  are  practically  the  same  at  all 
periods  of  pregnancy.  Recent  observations  have  shown  that 
syphilitic  changes  can  be  found  in  a  large  proportion  of 
such  ova. 

The  results  of  retention  of  a  dead  ovum  m  utero  vary  with 
the  conditions  present.  Infection  of  the  ovum  is  very  rare, 
and  is  only  found  in  cases  where  the  membranes  have  rup- 
tured, the  liquor  amnii  has  escaped,  and  an  open  channel  is 
left  through  which  vaginal  organisms  may  enter  the  ovum. 
Under  all  other  conditions  the  changes  are  non-infective. 

The  embryo  (first  and  second  months)  may  entirely  dis- 
appear by  autolysis  and  absorption.  At  later  periods  the 
foetus  at  first  undergoes  maceration  from  the  action  of  the 
surrounding  fluid.  The  epidermis  becomes  sodden,  bullae 
form  beneath  it,  and  finally  it  is  shed  in  pieces.  Gradual 
absorption  of  liquor  amnii  may  then  occur,  and  later  of  the 
fluid  constituents  of  the  embryonic  tissues  also.  The  foetus 
then  becomes  shrivelled,  or  mummified,  the  bones  standing 
out  clearly  beneath  the  thin  integuments.  The  foetus 
papyraceus  already  described'  exemplifies  this  change  also. 
During  the  process  of  maceration  the  liquor  amnii  becomes 
turbid  and  discoloured  ;  later  it  is  more  or  less  completely 
absorbed. 

The  detailed  changes  which  occur  are  as  follows  : — 

The  body  is  shrunken  and  the  skin  lax  and  loose.  Sub- 
cuticular bullae  are  formed  containing  discoloured  turbid 
fluid  ;  these  rupture,  and  after  shedding  of  the  detached 
cuticle,  dark  red  moist  areas  of  the  cutis  become  exposed. 
The  body  cavities  contain  turbid  reddish  fluid  in  moderate 
quantity.  The  articular  ligaments  become  softened,  allow- 
ing free  separation  of  the  bones  to  occur  ;  thus  the  trunk  may 
become  elongated,  and  the  skull  bones  may  be  made  to  over- 
lap, and  ride  easily  upon  one  another.  The  solid  viscera  are 
softened  and  ultimately  become  diffluent.  The  umbilical 
cord  is  stained  and  is  unusually  thick  from  softening  of 
Wharton's  jelly.  The  liquor  amnii  is  relatively  scanty  in 
amount  and  discoloured.  The  placenta  is  often  extensively 
infarcted,  but  this  is  an  ante-mortem  change.  Its  tissues  do 
not  soften  and  liquefy  like  those  of  the  foetus.  Attempts 
have  been  made,  without  much  success,  to  obtain  evidence 


DEAD   OVUM  239 

of  the  rate  at  which  these  changes  progress,  but  up  to  the 
present  time  no  rehable  data  can  be  given.  Occasionally 
absorption  into  the  maternal  circulation  of  toxic  products 
occurs,  giving  rise  to  fever,  debility,  malaria,  and  other  more 
or  less  definite  symptoms  of  toxaemia. 

The  placenta  and  membranes  undergo  non-putrefactive 
necrosis,  the  extra-placental  structures  being  first  affected. 
The  umbilical  vessels  on  the  placental  surface  become 
thrombosed.  The  placental  tissues  preserve  their  vitality 
much  longer,  because  the  maternal  circulation  is  only 
gradually  cut  off,  and  the  villi  therefore  remain  in  contact 
with  the  normal  source  of  their  nutrition.  Gradually,  how- 
ever, the  inter-villous  spaces  become  blocked  by  thrombosis, 
the  villi  necrose  and  lose  all  traces  of  their  characteristic 
structures,  until  they  become  mere  areas  of  structureless 
debris,  preserving  only  their  original  shape.  Lastly,  exten- 
sive fatty  and  calcareous  degenerations  occur  in  all  the  tissues. 
In  ova  altered  in  this  manner  by  post-mortem  changes,  it  is 
extremely  difficult  to  determine  the  primary  lesion  which 
caused  the  death  of  the  foetus. 

The  clinical  diagnosis  of  death  of  the  foetus  in  utero  can 
only  be  established  by  repeated  examinations.  The  most 
reliable  sign  is  cessation  of  growth  of  the  uterus,  and  at  least 
a  fortnight  is  required  to  determine  this  with  certainty,  the 
normal  rate  of  growth  being  about  |  inch  a  week.  Often 
an  actual  diminution  in  size,  from  absorption  of  the  fluid 
portion  of  the  ovum,  can  be  made  out  after  some  weeks. 
The'  uterus  is  usually  lax  and  flaccid,  and  it  is  difficult  to 
excite  contractions  by  manipulating  it.  During  the  last 
three  months  absence,  on  repeated  examinations,  of  the 
heart-sounds  is  important,  but  no  conclusion  can  be  drawn 
from  failure  to  hear  them  on  a  single  occasion.  Resolution 
of  breast-changes  can  sometimes  be  made  out,  and  is  often 
remarked  by  the  patient  herself.  Cessation  of  foetal  move- 
ments will  be  observed  by  the  mother,  but  these  must  not  be 
accepted  as  conclusive  evidence  unless  confirmed  by  other 
signs.  Other  symptoms,  such  as  a  feeling  of  weight  and  cold 
in  the  abdomen,  slight  shivering,  and  slight  general  malaise 
may  be  complained  of.  Sometimes  a  brownish  discharge 
from  the  uterus  is  observed,  consisting  of  the  liquefied  debris 
of  blood-clot  or  decidual  tissue,  but  it  is  extremely  rare  for  a 


240  ABNORMAL   PREGNANCY 

dead  ovum  to  undergo  putrefaction  in  utero,  except  as  the 
result  of  intra-uterine  manipulation. 

The  treatment  is  expectant  in  non-infective  cases.  Spon- 
taneous expulsion  will  occur  sooner  or  later,  and  there  is  no 
reason  for  interference  except  the  patient's  natural  desire  to 
get  her  labour  over.  At  the  same  time  it  must  be  remembered 
that  local  signs  of  putrefaction  render  necessary  immediate 
evacuation  of  the  uterus. 


Part   III 
NORMAL    LABOUR 

Labour  is  the  process  by  which  a  foetus  of  viable  age  is 
expelled  from  the  uterus.  Labour  varies  greatly  in  duration, 
in  severity,  and  in  the  amount  of  risk  to  mother  and  child 
which  it  involves.  By  a  normal  labour  is  meant  a  case  in 
which  the  foetus  presents  by  the  vertex,  and  which  terminates 
naturally,  without  artificial  aid  and  without  complications. 
Presentation  is  not  the  only  criterion  of  normal  labour,  for 
even  when  the  presentation  is  normal,  complications  may 
arise  which  carry  the  case  at  once  into  the  category  of 
abnormal  labour.  It  follows  that  abnormal  labour  is  some- 
what difficult  to  define,  but  for  practical  purposes  we  may 
include  under  this  designation  all  cases  in  which  some  other 
part  than  the  vertex  presents,  and  aU  vertex  cases  in  which 
complications  of  maternal  or  foetal  origin  arise. 

Within  the  class  of  normal  labour  many  conditions  must 
be  recognised  which  affect  the  degree  of  difficulty  which  may 
be  encountered.  Generally  spealdng  a  first  labour  is  more 
prolonged  and  more  difficult  than  subsequent  ones  ;  a  woman 
in  her  first  labour  is  conveniently  designated  as  a  primipara, 
in  later  confinements  as  a  multipara.  Another  factor  of  con- 
siderable importance  is  age  ;  from  eighteen  to  twenty  three 
years  is  the  age  at  which  the  first  labour  may  be  expected  to 
run  the  easiest  and  most  favourable  course.  A  primipara  of 
over  twenty-six  years  of  age  encounters  greater  risks,  which 
steadily  increase  in  gravity  as  age  advances.  From  sixteen 
to  eighteen  years  of  age  the  difficulties  are  not  materially 
greater  than  normal,  but  below  sixteen  there  is  more  risk  of 
serious  laceration. 

The  date  at  which  labour  may  be  expected  is  difficult  to 
determine.  The  average  duration  of  pregnancy  in  women  is 
generally  believed  to  be  forty  weeks.  This,  however,  is  an 
estimate  which  is  necessarily  approximate  not  precise.  The 
moment  at  which  pregnancy  begins,  i.e.,  the  fertilisation  of 

E.M,  16 


242 


NORMAL   LABOUR 


the  ovum,  cannot  be  determined,  and  it  is  here  that  abundant 
room  for  error  must  be  admitted.  The  data  available  in 
determining  the  beginning  of  pregnancy  are  :  (1)  the  last 
menstrual  period  ;  (2)  the  sexual  congress.  It  has  been 
already  mentioned  that  the  relation  of  the  former  to  the  act 
of  fertilisation  is  quite  unknown  ;  the  relation  of  the  latter  is 
of  service  only  when  a  single  act  of  coitus  has  occurred,  and 
even  then  we  do  not  know  how  long  an  interval  may  have 
elapsed  between  the  deposition  of  the  spermatozoa  in  the 
vagina  and  the  fertilisation  of  the  ovum.  For  practical  pur- 
poses therefore  these  data  cannot  be  relied  upon,  and 
allowance  must  be  made  in  the  estimate  for  the  unavoid- 
able inaccuracy.  The  '  calculated  '  date  at  which  labour 
may  be  expected  is  taken  to  be  280  days  (forty  weeks)  after 
the  commencement  of  menstruation.  This  must  not,  how- 
ever, be  regarded  as  an  exact  date,  but  as  the  central  point 
of  a  period  of  probability  ranging  from  the  274th  to  the 
286th  day.  The  calculation  may  be  made  as  follows  :  Last 
menstruation  January  31  to  February  5. 


February    . 
March 

28  (if  leap  year, 
31 

29) 

April . 
May  . 
June  . 

30 
31 
30 

July  . 
August 

31 
31 

September 
October 

30 
31 

November 

7 

280 


Therefore  the  confinement  may  be  expected  to  take  place 
between  November  2  and  12.  Labour  may  occur  at  an  earlier 
period  than  forty  weeks  when  it  is  said  to  be  premature  ; 
many  of  such  cases  are  due  to  pathological  conditions,  but 
sometimes  no  cause  can  be  assigned.  On  the  other  hand  the 
onset  of  labour  may  be  delayed  considerably  beyond  the 
normal  period,  when  it  is  said  to  be  postmature.  It  is  very 
uncommon   for   the   calculated   duration   of   pregnancy  to 


LABOUR   PAINS  243 

exceed  300  days,  but  an  instance  has  been  recorded  by  von 
Winckel  in  which  it  was  322  days.  Owing  to  the  difficulties 
referred  to  above  an  exact  estimate  of  postmaturity  is  im- 
possible. Calculation  may,  however,  be  controlled  by  two 
other  factors  :  (a)  the  length  and  weight  of  the  foetus,  which 
considerably  exceed  the  normal  ;  (6)  the  condition  of  the 
foetal  centres  of  ossification  as  determined  by  radiography  ; 
these  have  been  worked  out  by  Keith  for  the  normal  foetus  at 
term,  and  a  considerable  advance  upon  his  data  may  be 
accepted  as  evidence  of  postmaturity.  The  details  cannot 
be  discussed  here. 

It  is  obvious  that  while  the  birth  of  a  premature  child 
will  be  easier,  the  delivery  of  a  child  whose  weight  and  size 
greatly  exceed  the  normal  will  be  attended  by  increased  risks, 
and  consequently  the  subject  of  postmaturity  is  not  without 
clinical  importance.  It  will  be  again  referred  to  in  connection 
with  the  induction  of  premature  labour  (p.  653). 

The  Onset  of  Labour. — The  signs  by  which  the  onset 
of  labour  is  recognised  must  be  clearly  understood.  They 
are  (1)  painful  uterine  contractions  ;  (2)  slight  uterine 
hsemorrhage^ — the  '  show  '  ;  (3)  commencing  dilatation  of 
the  internal  os  ;   (4)  formation  of  the  '  bag  of  waters.' 

(1)  Painful  Uterine  Contractions  (Labour  Pains). — 
Reference  has  already  been  made  to  the  fact  that  during  the 
second  half  of  pregnancy  intermittent  contractions,  recog- 
nisable on  palpation,  occur  in  the  wall  of  the  gravid  uterus. 
The  patient  is  unconscious  of  them,  and  they  produce  no 
effect  upon  the  cervix  or  ovum.  At  '  term  '  these  contrac- 
tions change  their  character  and  become  labour  pains  ; 
usually  the  transformation  is  gradual,  vague  transient  ab- 
dominal pain  being  complained  of  by  the  patient  for  several 
days  ;  sometimes,  however,  a  rapid  or  sudden  onset  of  labour 
pains  will  be  met  with.  At  first  they  are  slight,  lasting  for 
only  half  a  minute,  and  separated  by  intervals  of  fifteen  to 
thirty  minutes  ;  they  are  then  felt  chiefly  in  the  abdomen. 
More  or  less  rapidly  they  increase  in  frequency,  severity,  and 
duration.  If  the  abdomen  is  palpated  during  a  pain,  the 
whole  uterus  will  be  felt  to  harden  and  become  more  clearly 
defined  in  outline. 

In  women  expecting  to  be  confined,  colicky  abdominal 
pains,  which  may  sometimes  be  mistaken  by  the  patient  for 

16—2 


244 


NORMAL  LABOUR 


labour  pains,  are  apt  to  occur  from  such  trivial  causes  as 
dyspepsia  and  constipation.  They  have  received  the  some- 
what inept  name  of  '  false  pains.'  Pain  of  this  description  is 
not  accompanied  by  dilatation  of  the  internal  os  or  contrac- 


Thickened  cervical  mucosa 


Fig.  97. — Cervix  of  a  Multipara  at  Term,  before  Commencement  of 
Laboui'.     From  a  Frozen  Section.     (Varnier.) 


tion  of  the  uterus,  and  need  therefore  never  be  mistaken  for 
labour  ;   it  is  best  treated  by  an  aperient  or  an  enema. 

(2)  The  '  Show  '  is  a  discharge  of  slightly  blood-stained 
mucus.  The  mucus  comes  from  the  cervical  mucosa,  which 
secretes  abundantly  during  labour  ;  the  slight  hsemorrhage 
comes  from  the  lower  uterine  segment,  where  the  com- 
mencement of  dilatation  causes  a  little  separation  of  the 


DILATATION 


245 


membranes.    It  is  almost  invariably  met  with  at  the  onset 
of  labour.   .  . 

(3)  Dilatation  of  the  Internal  Os. — The  usual  condition  of 
the  cervix  at  term,  before  the  onset  of  labour,  is  shown  in 
Fig.  97.  From  this  figure  it  will  be  seen  that  the  cervix  is  not 
shortened  ;  the  canal  is  intact  and  closed  at  both  ends.  In 
a  multipara  the  external  os  is  sometimes  patulous,  admitting 
the  tip  of  the  index  finger,  but  even  then  the  internal  os  will 
usually  be  found  closed  before  labour.  The  alterations 
induced  by  the  onset  of  labour  are  shown  in  Fig.  98,  where  it 
will  be  seen  that  the  cervix  is  shortened,  and  the  canal  open 


Scalp 


Amniotic  fluid 


Uterine   wall 


Bag  of  waterfr 


vagjna 

Fig.  98. — Cervix  ot  a  Multipara  who  died  of  Eclampsia  at  the  beginning 
of  Laboiu'.     From  a  Frozen  Section.     (Varnier.) 

at  both  ends,  the  internal  os  being  rather  wider  than  the 
external.  These  figures  represent  the  actual  conditions  found 
in  frozen  sections  of  women  who  died,  the  former  before 
labour,  the  latter  soon  after  its  commencement ;  they  have 
therefore  the  value  of  precise  anatomical  observations.  It 
will  be  noticed  that  the  dilatation  of  the  internal  os  is  of 
necessity  accompanied  by  a  corresponding  stretching  of  the 
lowest  part  of  the  lower  uterine  segment.  Notwithstanding 
what  has  just  been  said,  the  internal  os  is  not  infrequently 
found  dilated  sufficiently  to  admit  the  finger  tip  in  women 
who  are  not  in  labour  ;  this  is  more  frequently  found  in  a 
multipara  than  in  a  primipara.     In  some  cases  it  is  the  result 


246  NORMAL   LABOUR 

of  a  false  start,  a  few  effective  pains  having  occurred  and  then 
died  away.  In  others  there  is  no  history  of  definite  pains 
having  been  felt,  and  this  slightly  patulous  condition  of 
the  internal  os  may  appear  two  or  three  weeks  before  labour 
actually  sets  in. 

The  position  is,  therefore,  that,  while  a  closed  cervix  is  a 
reliable  sign  that  labour  has  not  begun,  a  slightly  patulous 
cervix  may  be  found  in  a  woman  who  is  not  in  labour. 

(4)  Formation  of  the  '  Bag  of  Waters.' — When  the  cervix 
opens,  the  lower  pole  of  the  foetal  membranes  (chorion  and 
amnion),  which  has  been  already  detached  by  stretching  of 
the  lower  uterine  segment,  being  unsupported,  tends  to 
bulge  into  the  cervical  canal.  It  contains  a  little  liquor 
amnii  which  has  passed  below  the  presenting  part,  and  it  has 
therefore  received  the  name  of  the  '  bag  of  waters.'  When 
the  finger  is  passed  into  the  cervix  during  a  pain,  this  bag  will 
be  found  to  be  convex  in  outline  and  tense  in  consistence  ; 
as  the  pain  passes  off  it  becomes  less  tense  and  less  distinct, 
and  may  even  disappear  altogether  as  the  membranes  come 
into  contact  again  with  the  head. 

Notwithstanding  these  points,  it  is  at  times  somewhat 
difficult  to  decide  from  a  single  examination  whether  a  patient 
is  actually  in  labour  or  not.  Pains  sufficient  to  open  the 
internal  os  may  occur  and  then  cease,  several  days  or  even 
two  or  three  weeks  elapsing  before  the  actual  onset  of  labour. 
Again,  the  patient  may  complain  of  intermittent  pains,  and 
uterine  contractions  may  actually  be  felt  on  palpation,  yet 
there  may  be  no  dilatation  of  the  cervix  at  all.  It  follows 
that  neither  painful  contractions  alone,  nor  dilatation  of 
the  cervix  alone,  suffices  for  recognising  that  labour  is 
actually  in  progress.  But  if  with  intermittent  pains  and 
dilatation,  the  bag  of  waters  is  felt  to  grow  tense  during  the 
pain,  and  to  relax  during  the  interval,  the  diagnosis  of  labour 
is  certain.  Yet  after  labour  has  actually  begun  the  process  is 
sometimes  suspended,  and  the  pains  do  not  start  again  until 
an  interval  of  several  days  has  elapsed. 

The  Stages  of  Labour. — In  this  country  it  is  usual  to 
divide  the  process  of  labour  into  three  stages.  In  most 
instances  these  stages  can  be  clinically  defined  with  approxi- 
mate accuracy,  but  sometimes  cases  occur  in  which  this  is 
impossible. 


DILATATION  247 

First  Stage,  or  Stage  of  Dilatation. — This  stage  is  pre- 
paratory to  the  actual  process  of  birth — i.e.,  the  expulsion  of 
the  foetus  from  the  uterus.  It  consists  in  the  dilatation  or 
canalisation  of  the  lower  uterine  segment  and  cervix. 
Clinically  its  progress  can  be  judged  by  the  changes  taking 
place  in  the  os  externum,  the  cervix,  and  the  bag  of  waters. 

Even  when  in  a  multipara  the  external  os  is  patulous  at 
the  commencement  of  labour  the  vaginal  portion  of  the  cervix 
is  distinctly  felt  forming  a  projection  of  about  half  an  inch  in 
length.  As  the  internal  os  opens  the  upper  part  of  the  cer- 
vical canal  becomes  merged  in  the  lower  uterine  segment  ; 
as  the  dilatation  progresses,  more  of  the  cervix  becomes  thus 
'  taken  up  '  into  the  uterus,  and  this  change  can  be  detected 
by  the  finger  as  a  shortening  of  the  cervical  projection  on 
vaginal  examination.  When  no  definite  cervical  projection 
can  be  felt  the  cervix  is  said  to  be  '  taken  up,'  although  the 
external  os  may  still  be  only  partially  dilated.  In  a  primi- 
gravida  the  os  externum  sometimes  remains  very  small  after 
the  cervical  canal  has  become  merged  in  the  lower  segment  ; 
the  head  then  distends  the  cervical  canal,  the  walls  of  which 
become  tightly  stretched  over  it.  The  os  is  then  felt  as  a 
small  aperture  with  firm  edges  upon  the  summit  of  the  con- 
vexity formed  by  the  distended  cervix,  which  has  been 
completely  '  taken  up.'  But  as  a  rule  the  bag  of  waters 
bulges  slightly  through  the  dilating  external  os  in  the  shape 
of  an  inverted  watch-glass  (Figs.  98  and  99)  ;  the  amount 
of  fluid  it  contains  varies  considerably,  and  upon  this  its 
size  and  shape  depend.  During  the  intervals  when  the  bag 
is  lax  the  foetal  head  can  be  distinctly  felt  through  it. 
When,  as  sometimes  happens,  the  membranes  rupture  before 
the  onset  of  labour,  no  bag  is  as  a  rule  formed,  although 
exceptions  to  this  may  be  met  with  (see  p.  453).  When 
dilatation  is  complete  the  diameter  of  the  cervical  canal  is 
nearly  four  inches,  the  presenting  part  occupies  the  whole 
cervical  canal,  and  the  edges  of  the  os  externum  can  be  felt 
surrounding  it.  At  this  period  the  bag  of  waters  usually 
ruptures  spontaneously,  and  a  certain  amount  of  liquor 
amnii  escapes,  but  the  greater  part  is  retained  in  the  uterus, 
the  presenting  part  filling  the  lower  uterine  segment  and 
thus  acting  as  a  ball-valve.  Sometimes,  however,  rupture 
of  the  membranes  occurs  prematurely  in  the  first  stage  ;  or 


248 


NORMAL   LABOUR 


on  the  other  hand,  it  may  be  delayed  until  the  second  stage 
is  considerably  advanced  ;  in  exceptional  cases  it  may  not 
occur  at  all,  the  bag  protruding  at  the  vulva  and  the  head 
being  still  enclosed  in  the  membranes.  As  a  rule,  however, 
in  such  cases  the  chorion  ruptures,  allowing  the  amnion  to 
protrude  through  it,  and  it  is  the  latter  membrane  alone 
which  presents  at  the  vulva. 

The   duration  of  this   stage  is   variable,  being  usually 


OS  externum 


Bag-  of 
waters 


Anterior  lip  of 
OS  externum 


Fig.  99. — End  of  the  First  Stage  of  Laboui-.  The  Lower  Uterine  Seg- 
ment, Cervix,  and  Upper  Part  of  the  Yagiua  are  dilated.  (Modified 
fi-om  Eibemont-Dessaignes  and  Lepage.) 

much  longer  in  a  primipara  than  in  a  multipara.  Its  average 
may  be  stated  as  sixteen  hours  in  the  former,  and  eight 
hours  in  the  latter.  The  patient  suffers  throughout  from 
intermittent  pam,  felt  chiefly  in  the  abdomen,  occurring  at 
more  or  less  regular  intervals  of  from  three  to  five  minutes  ; 
frequently  there  is  vomiting  in  this  stage,  but  the  pulse  and 
temperature  remain  normal. 

Second  Stage,  or  Stage  of  Expulsion. — This  stage  begins 
at  the  time  when  dilatation  of  the  cervix  is  complete,  whether 


EXPULSION 


249 


CORONARY  mk--^ 

UTtR0-yE5icAL  pouch:^ 

BLfiDDER'- 
5YMPHY5I5    PUBIS-' 


'\PO'SITII^M  OF 
Oj£XT^RMUM 


BAG  OF  IVATERS   , 

(^MhiOfi  ?.  chorion] 


Fig.  100. — Section  showing  the  Second  Stage  of  Labour.  The  Os  is  fully 
dilated,  and_  the  unruptured  Bag  of  Waters  jiresents  at  the  Vulva. 
The  Uterus  is  thrown  forwards  away  from  the  Spine,  and  no  Sinuses 
are  seen  in  the  Uterine  Wall,  showing  that  death  occurred  during  a 
contraction  and  passed  into  rigor  mortis. ^  (Braune,  from  Barbour's 
Anatomy  of  Labour.) 


1  Note. — Flexion  is  deficient ;  the  right  arm  lies  under  the  chin  ;  internal 
rotation  is  nearly  complete. 


250 


NORMAL   LABOUR 


accompanied  by  rupture  of  the  membranes  or  not  ;   it  ends 
■with  the  complete  expulsion  of  the  child  from  the  birth- 


fd-i'ESICAL 
POUCH 


lADDER 


^.Sl5  PUBIS 


'0  OFmiRS 


Fig.  101.— Section  showing  the  End  of  the  Second  Stage  of  Labour.  The 
Axis  of  the  Uterus  is  parallel  to  the  Spine,  and  the  Sinuses  in  the  Wall 
are  open,  showing  that  death  occurred  during  relaxation. i  (Chiara, 
from  Barbour's  Anatomy  of  Labour.) 

canal.     The  presenting  part  is  now  passing  from  the  cervix 
into  the   vagina,    and    on  examination  the  lip  of  the  os 

1  Note. — Flexion  is  deficient  ;  the  head  lies  in  the  transverse  diameter. 


EXPULSION 


251 


externum  cannot  be  felt  posteriorly,  but  is  still  within  reach 
anteriorly.  It  will  be  observed  that  during  this  stage  the 
vagina  becomes  gradually  dilated  from  above  downwards 
(Fig.  100)  by  the  passage  through  it  of  the  head  and  body 
of  the  foetus.  The  condition  of  the  birth-canal  towards  the 
end  of  the  second  stage,  but  before  the  actual  expulsion  of 
the  child,  is  seen  in  Fig.  101,  which  shows  that  the  uterus, 


Fig.  102. — Birth  of  Head:  Scalp  appearing  at  Vulva. 
(Whitridge  Williams.) 


cervix,  and  vagina  have  been  merged  into  a  single  broad 
channel,  the  boundaries  between  the  component  parts 
having  been  obliterated. 

The  expulsion  of  the  child  is  accomplished  by  the  uterus, 
strongly  reinforced  by  the  voluntary  muscles,  which  are 
vigorously  used  by  the  patient.  The  participation  of  the 
voluntary  muscles  is  the  chief  factor  in  causing  the  charac- 
teristic feature  of  the  pains  of  the  second  stage.     The  onset 


252 


NORMAL  LABOUR 


of  each  pain  is  accompanied  by  a  deep  inspiration,  followed 
by  straining  or  '  bearing  down/  in  which  the  patient  holds 
her  breath  and  employs  her  diaphragm,  abdominal  and  back 
muscles,  and  sometimes  apparently  all  the  muscles  in  her 
body.  The  face  becomes  congested,  the  pulse  quickened,  she 
perspires  a  little  and  groans  deeply  during  the  pains.     They 


Fig.  103. — Birtli  of  Head  :  'Vulva  completely  dilated. 
(WMtridge  Williams.) 

last  much  longer  and  recur  more  frequently  than  those  of 
the  first  stage. 

When  the  head  reaches  the  pelvic  floor,  the  first  change 
observed  in  the  external  genitals  is  stretching  of  the  perineal 
body,  which  during  the  pains  becomes  somewhat  convex 
externally  and  lengthened  from  anus  to  vulva  (Fig.  102). 
Next  the  anus  becomes  turgid  and  dilates  slightly,  and  the 
hairy  scalp  appears  at  the  vulva  (Fig.  103).  As  each  pain 
passes  off,  the  parts  resume  their  normal  appearance.   When 


EXPULSION  253 

the  head  is  about  to  emerge  the  anus  gapes  widely,  exposing 
one  to  two  inches  of  the  anterior  rectal  wall.  The  fourchette 
becomes  greatly  thinned  as  the  vulva  stretches,  and  a  certain 
amount  of  laceration  of  the  posterior  wall  of  the  ostium 
vaginae  may  be  expected  to  occur.  This  usually  also  involves 
the  lower  part  of  the  posterior  vaginal  wall  and  at  times  the 
perineal  body,  which  may  in  some  instances  be  torn  up  to  or 
including  the  anus.  The  actual  expulsion  of  the  head  in 
a  primipara  is  accomplished  by  a  very  prolonged  and  severe 
contraction,  or  by  a  series  of  powerful  contractions,  accom- 
panied by  violent  straining. 

A  short  pause  then  occurs,  to  be  succeeded  in  two  or  three 
minutes  by  a  return  of  the  pains,  which  expel  first  the 
shoulders,  and  then  the  trunk  and  lower  extremities.  In  the 
case  of  a  large  foetus,  the  expulsion  of  the  shoulders  may 
cause  as  much  laceration  of  the  vulva  as  the  delivery  of  the 
head.  As  the  body  escapes  a  rush  of  blood-stained  liquor 
amnii  follows,  representing  the  portion  of  fluid  which  has 
been  retained  in  the  uterus  along  with  the  trunk  and  limbs. 
The  second  stage  lasts  on  an  average  three  hours  in  a  primi- 
para ;  in  a  multipara  it  is  often  very  short,  lasting  only 
ten  to  fifteen  minutes  when  the  uterus  acts  powerfully  ;  but 
it  may  last  very  much  longer  than  this  when  the  pains  are 
relatively  feeble. 

Third  Stage,  or  Delivery  of  the  After-birth. — The  after- 
birth consists  of  the  placenta,  umbilical  cord,  and  mem- 
branes ;  the  latter  include  the  amnion,  chorion,  and  some- 
times the  remains  of  the  decidua  vera. 

Following  upon  the  expulsion  of  the  foetus,  the  uterus 
undergoes  a  sudden  and  striking  diminution  in  size.  The 
fundus  now  lies  about  the  level  of  the  umbilicus,  and  the 
uterus  appears  to  be  about  as  large  as  the  foetal  head.  It 
will  be  observed  to  vary  gradually  in  consistence,  becoming 
alternately  harder  and  softer  to  the  touch  ;  this  signifies  that 
intermittent  contractions  are  continuing,  but  they  are 
practically  painless,  and  the  patient  is  usually  unconscious 
of  them.  After  a  period  varying  on  an  average  from  ten  to 
thirty  minutes,  certain  changes  occur  which  indicate  that  the 
placenta  has  been  detached  from  the  uterine  wall  and  driven 
into  the  lower  uterine  segment  and  cervix,  or  into  the  vagina. 
The  uterus  becomes  smaller,  harder,  more  globular  in  shape, 


254  NORMAL   LABOUR 

and  more  freely  movable  from  side  to  side  ;  the  level  of  the 
fundus,  which  is  hard  and  retracted,  rises,  while  the  lower 
segment,  now  plainly  felt  above  the  pubes,  is  soft  and  bulging 
from  the  presence  in  it  of  the  placenta.  It  may  also  be 
noticed  that  the  length  of  the  umbilical  cord  lying  outside 
the  vulva  is  greater  than  before.  A  certain  amount  of 
hsemorrhage  always  accompanies  the  process  of  separation 
of  the  placenta.  Expulsion  is  usually  accomplished  by  a 
voluntary  effort  on  the  part  of  the  patient,  when  the  placenta 
appears  at  the  vulva,  and  can  be  withdrawn  by  the  atten- 
dant ;  a  considerable  amount  of  blood-clot  often  follows  it. 
The  uterus  is  now  about  the  size  of  a  cricket-ball,  and 
should  remain  almost  uniformly  firm  and  hard  ;  but  for 
some  hours  after  labour  intermittent  spontaneous  contraction 
and  relaxation  can  often  be  recognised,  and  while  these 
continue  there  is  a  risk  of  haemorrhage. 

The  Anatomy  and  Physiology  of  the  First  and 
Second  Stages  of  Labour. 

In  this  section  will  be  described  (I.)  the  maternal  passages 
and  the  effects  of  labour  upon  them  ;  (II.)  the  foetus  at  term 
and  the  effects  of  labour  upon  it  ;  (III.)  the  forces  of  labour, 
their  mode  of  action,  and  their  influence  upon  the  general 
physiological  functions  of  the  mother. 

I.  The  Maternal  Passages. — These  comprise  the  bony 
canal  with  the  soft  structures  which  Une  it  and  close  in  its 
outlet. 

A  description  of  the  general  anatomy  of  the  pelvis  is 
unnecessary  in  a  text-book  of  midwifery  ;  it  will,  however,  be 
useful  to  recall  the  points  of  difference  between  the  male  and 
female  pelvis  (Figs.  104  and  105).  In  the  female  the  bones  are 
more  slender  and  the  muscular  impressions  less  pronounced. 
The  false  pelvis  (the  part  above  the  pelvic  brim,  and  bounded 
laterally  by  the  ihac  bones)  is  somewhat  more  capacious  in 
the  female  than  in  the  male,  the  anterior  superior  iliac  spines 
being  a  little  further  apart,  and  the  ihac  fossae  looking  more 
directly  forwards.  In  the  female  the  true  pelvis  is  somewhat 
more  capacious,  though  a  little  shallower  ;  the  sacral  pro- 
montory projects  less  into  the  brim  ;  the  sacrum  is  rather  less 
concave  anteriorly  ;   the  pelvic  outlet  is  considerably  larger 


THE   PELVIS 


255 


in  all  its  diameters,  and  the  pubic  arch  forms  a  much  more 
obtuse  angle.  Sometimes  a  female  pelvis  approximates  to 
the  male  characteristics,  leading  to  a  certain  amoiint  of 
difficulty  in  labour. 

With  the  false  pelvis  we  have  little  concern  except  that 
its  dimensions  are  of  service  in  indicating  the  shape  and  size 
of  the  true  pelvis  ;  these  will  be  mentioned  in  describing 
clinical  pelvimetry  (p.  401).     The  true  pelvis  is  divided  for 


Fig.  104. — Female  Pelvis* 


systematic  description  into  three  parts — ^viz.,  the  brim,  the 
outlet,  and  the  cavity. 

The  pelvic  brim  or  inlet,  or  upper  pelvic  strait,  is  the  plane 
of  division  between  the  false  and  the  true  pelvis  (Fig.  106). 
It  may  be  traced  from  the  centre  of  the  upper  border  of  the 
symphysis  pubis  (b),  along  the  pubic  crest,  past  the  pubic 
spine  to  the  ilio-pectineal  eminence  (/),  thence  along  the  iliac 
portion  of  the  ilio-pectineal  line  to  the  sacro-iliac  sjmchon- 
drosis  (g),  thence  along  the  ala  of  the  sacrum  to  the  centre  of 
the  sacral  promontory  (a).  Its  shape  is  that  of  a  transverse 
oval,  with  a  slight  posterior  constriction  caused  by  the  pro- 
montory of  the  sacrum  {i.e.,  it  is  roughly  cordate.  Fig.  110). 
We  have  to  consider  its  plane,  its  inclination,  its  axis,  and  its 


256 


NORMAL   LABOUR 


diameters.  The  'plane  of  the  pelvic  brim  is  an  imaginary  flat 
surface  bounded  by  the  hmits  just  mentioned  as  those  of  the 
brim  ;  it  is  convenient  to  speak  of  the  presenting  part  of  the 
fcBtus  as  lying  above,  or  below,  or  in  the  plane  of  the  brim. 
The  plane  of  the  brim  is  not,  in  the  erect  position  of  the  body, 
a  horizontal  surface,  but,  owing  to  the  obhque  articulation 
of  the  pelvis  with  the  femora,  it  is  inclined  at  an  acute  angle 
to  the  horizon  ;  this  is  its  inclination.  This  will  be  clear 
from  Fig.  107  {a),  which  represents  a  bisected  pelvis,  placed 


Fig.  105. — Male  Pelvis. 


in  the  position  it  would  occupy  in  the  erect  attitude.  The 
general  inclination  of  the  line  of  the  brim  is  well  seen.  The 
same  points  are  shown  diagrammatically  in  Fig.  107  (&), 
which  shows  that  the  angle  of  inclination  in  the  erect 
position  is  55°.  The  posterior  border  of  the  brim  accordingly 
stands  at  a  higher  level  than  the  anterior,  the  sacral  pro- 
montory being  about  3f  inches  above  the  upper  border  of  the 
symphysis  pubis  in  the  erect  position.  It  must  also  be 
observed  that  the  surface  of  the  body  of  the  pubes  is  not 
vertical,  but  almost  at  right  angles  to  the  plane  of  the  brim. 
The  axis  of  the  brim  will  be  represented  by  an  imaginary 


THE   PELVIS 


257 


straight  line  drawn  perpendicular  to  the  plane  of  the  brim  at 
its  centre  ;  this  being  produced  upwards  and  downwards, 
will  pass  from  the  umbilicus  to  the  tip  of  the  coccyx  (Fig.  109). 
This  line  indicates  the  direction  in  which  a  body  passing 
through  the  pelvic  brim  must  travel.  Four  diameters  of  the 
pelvic  brim  are  described  ;  it  must  be  recollected  that  they 
are  skeletal  measurements  and  represent  averages  from 
which  slight  variations  in  both  directions  occur.  The 
antero-posterior  diameter  or  conjugate  is  measured  from  the 
centre  of  the  sacral  promontory  behind  to  the  nearest  point 


Fig.  106.— The  Female  Pelvis :  Outline  of  Pelvic  Brim,  a,  e,  d,  h,  h,  f,  c,  g. 

a,  b.  Conjugate  diameter,     c,  d.  Transverse  diameter,     e,  f.  Left  oblique  diameter. 
g,  h.  Right  oblique  diameter. 

in  the  middle  line  upon  the  posterior  surface  of  the  symphysis 
pubis  in  front  (Fig.  106,  a,  b).  This  diameter  is  also  called 
the  obstetric  or  true  conjugate,  to  distinguish  it  from  certain 
clinical  measurements  to  be  afterwards  described,  which  are 
also  called  conjugates.  The  two  oblique  diameters  are 
measured  from  the  sacro-iliac  synchondrosis  behind  to  the 
ilio-pectineal  eminence  on  the  opposite  side  ;  the  right 
oblique  is  that  taken  from  the  right  sacro-iliac  joint  {g,  h), 
the  left  from  the  left  sacro-iliac  joint  (e,  /).  A  transverse 
diameter  is  also  described,  being  the  distance  between  the 
two  furthest  apart  points  of  the  pelvic  brim  (c,  d)  ;  this  line 

Jl.M,  17 


258 


NORMAL   LABOUR 


lies  nearer  the  sacrum  than  the  pubes,  and  is  not,  strictly 
speaking,  a  diameter  at  all  since  it  does  not  pass  through  the 
centre. 

The  pelvic  outlet  or  lower  pelvic  strait  is  a  lozenge-shaped 
space  bounded  in  front  by  the  lower  border  of  the  symphysis 
pubis  ;  laterally  by  the  pubic  arch,  the  ischial  tuberosities, 
the  ischial  spines,  and  the  greater  and  lesser  sacro-sciatic 
ligaments  ;    posteriorly  by  the  coccyx   (Fig.    108).     These 


Pubic 
spine 


Fig.  107. — (a)  A  Bisected  Pelvis,  as  in  the  Erect  Position,  showing 
the  Inclination  of  the  Pelvic  Brim.  (6)  The  same  represented 
Diagrammatically. 

boundaries  do  not  lie  in  a  single  plane  ;  hence,  strictly 
speaking,  the  j^lcme  of  the  outlet  does  not  exist,  for  its  lateral 
boundaries  lie  at  a  lower  level  than  the  front  and  back.  It 
is  of  great  practical  importance,  however,  to  determine  the 
axis  of  the  outlet,  and  it  has  consequently  been  agreed  to 
describe  its  plane  as  the  imaginary  fiat  surface  bounded  in 
front  by  the  lower  border  of  the  symphysis,  laterally  by  the 
tips  of  the  ischial  spines,  and  posteriorly  by  the  lower  border 
of  the  last  sacral  vertebra.     As  thus  defined,  its  shape  is  that 


THE   PELVIS 


259 


of  an  antero-posterior  oval  (Fig.  110).  Its  axis  will  be  repre- 
sented by  a  line  joining  the  centre  of  its  plane  with  the  sacral 
promontory — a  line  much  more  nearly  vertical  than  the  axis 
of  the  brim  (Fig.  109).  Only  two  diameters  can  be  described : 
the  antero-posterior,  taken  from  the  centre  of  the  lower  border 
of  the  symphysis  to  the  tip  of  the  last  sacral  vertebra  (Fig. 
108)  ;  and  the  transverse  between  the  inner  borders  of  the 
ischial  tuberosities.  Oblique  diameters  cannot  be  defined, 
as  between  the  ischial  tuberosities  and  the  coccygeal  border 


Fig.  108.— The  Pelvic  Outlet :  Lower  Pelvic  Strait. 
a,  6.  Antero-posterior  diameter,    c,  d.  Transverse  diameter. 

the  pelvic  outlet  is  filled  in  with  soft  structures  only,  and  the 
diameters  we  are  considering  are  skeletal. 

It  will  be  obvious  that  the  length  of  antero-posterior 
diameter  is  reduced  by  the  forward  projection  of  the  coccyx 
in  the  skeleton.  During  labour,  however,  the  movement  of 
the  coccyx  at  the  sacro-coccygeal  joint  carries  it  backwards, 
so  that  the  length  of  the  diameter  is  not  much  affected. 
When  the  sacro-coccygeal  joint  is  ankylosed  this  movement 
cannot  occur  and  the  available  diameter  is  reduced. 

The  pelvic  cavity  is  the  space  between  the  plane  of  the 
brim  above  and  the  plane  of  the  outlet  below.  It  forms  a 
curved  canal  with  a  shallow  anterior  and  a  deep  posterior 
wall ;  the  former  measuring  1|  inches,  the  latter  4|  inches ; 
its  lateral  walls  are  about  4  inches  deep.  It  is  obvious  that 
a  number  of  planes  of  the  cavity,  taken  at  different  levels, 

17—2 


260 


xor:\l\l  labour 


might  be  descfibed.  but  it  suffices  to  determine  a  single 
one — the  mid-plane,  bounded  in  front  by  the  centre  of  the 
symphysis  pubis,  and  behind  by  the  junction  of  the  second 
and  third  sacral  vertebrse.  Its  shape  is  intermediate  between 
that  of  the  brim  and  that  of  the  outlet  (Fig.  110).  Its  antero- 
posterior  diameter  is  measured  from  the  points  just  mentioned, 
its  transverse  diameter  across  the  widest  part  ;  oblique 
diameters  cannot  be  precisely  defined,  owing  to  the  soft 
structures  filling  in  the  sacro-sciatic  notches.   The  axis  of  the 


EiG.  109. — The  Planes  and  Axes  of  the  Xormal  Pelvis. 

A,  B.  Horizontal  line.     G,  B.  Plane  of  the  brim.     J,  I.  Plane  of  the  mi(i-ca\-ity.     F,  E.  Plane 
of  the  outlet.     D,  C.  Axis  of  the  hrim.     G,  H.  Axis  of  the  outlet. 


mid-plane  of  the  cavity  is  represented  hj  a  line,  the  dii'ection 
of  which  is  intermediate  between  those  of  the  brim  and  the 
outlet.  By  unitmg  the  axes  of  the  three  planes  of  the  brim, 
mid-cavity,  and  outlet,  a  line  is  formed  which  will  traverse 
the  centre  of  the  canal  of  the  bony  pelvis  (Fig.  112).  It 
forms  a  curve,  concave  anteriorly,  and  directed  at  first 
downwards  and  backwards  (axis  of  brim),  then  gradually 
more  and  more  forwards  until  it  reaches  the  axis  of  the  out- 
let. It  is  of  great  service  in  the  systematic  description  of 
labour,  but  does  not  strictly  foUow  the  centre  of  the  canal,  as 
no  allowance  is  made  for  the  iiTegidaf  curvature  of  the 


THE   PELVIS 


261 


anterior  surface  of  the  sacrum.  This  line  is  known  as  the 
axis  of  the  pelvis  or  curve  of  Carus  ;  in  labour  it  becomes 
modified  by  displacement  of  the  pelvic  floor,  and  will  be 
again  referred  to  in  that  connection. 

The  average  length  of  the  diameters  of  the  bony  pelvis 
is  as  follows  : 


Brim  (plane)  . 
Cavity  (mid-plane) 
Outlet  (plane) 


Ant. -Post.  Oblique. 

4^  in.  (10-5  cm.)    4|  in.  (12      cm.) 
4|  „    (12      „    )    5     „    (12-5    „  ) 


(13 


)    U  „    (11-5    ,,  ) 


Transverse. 
5j  in.  (13    cm.) 
4|  „    (12     „    ) 
H  „    (10-5  „    ) 


The   oblique   diameters   of   the   cavity   and   outlet   are 
approximate,    for    the    reasons    already    mentioned.     The 


Fig.  no.-  The  Planes  (a)  of  the  Brim,  (b)  of  the  Cavity,  (c)  of  the  Outlet. 
The  double-lieaded  arrow  represents  the  longest  diameter. 


antero-posterior  diameter  of  the  outlet  is  clinically  measured 
from  the  lower  border  of  the  symphysis  to  the  tip  of  the 
coccyx  instead  of  to  the  lower  border  of  the  last  sacral 
vertebra.  With  the  coccyx  pushed  back  to  the  fullest 
possible  extent  in  the  position  it  assumes  in  normal  labour 
when  the  foetal  head  passes  through,  it  measures  5|  inches  ; 
with  the  coccyx  in  its  normal  position  it  is  f  to  1  inch  less 
than  this. 

These  diameters  are  reduced  by  the  soft  structures  which 
line  the  pelvic  walls  and  by  the  viscera  contained  within  the 
pelvis.  The  ilio-psoas  and  obturator  internus  muscles  reduce 
the  transverse  and  oblique  diameters  at  the  brim.  The 
pelvic  colon  and  upper  part  of  the  rectum  lie  in  the  left 
oblique  diameter  both  of  the  brim  and  the  cavity;  in  par- 
turient women  the  conjugate  of  the  brim  passes  through  the 


262 


NORMAL  LABOUR 


urethra  and  through  both  walls  of  the  cervix,  which  diminish 
the  space  available  for  the  accommodation  of  the  presenting 
part  of  the  fcBtus.  Frozen  sections  show  that  in  the  second 
stage  the  available  space  in  the  conjugate  diameter  is  thus 
diminished,  at  the  brim  from  J  to  ^  inch,  in  the  cavity  from 


to  I  inch. 


The  pelvic  floor  comprises  the  soft  parts  which  fill  in  the 
pelvic  outlet.  For  a  general  description  oi  the  structures 
of  which  it  is  composed  a  text-book  on  anatomy  should  be 


Perineal 


Fig.  111. — Sclaematic  Eej)resentation  of  the  Disjjlacement  of  the 
Pelvic  Floor  in  Labour.     (Dakin.) 

consulted  ;   we  are  only  concerned  with  the  changes  which  it 
undergoes  during  labour. 

Under  ordinary  conditions  the  outer  or  lower  surface  of 
the  pelvic  floor  (the  anatomical  perineum)  is  somewhat 
convex,  the  centre  of  the  permeal  body  being  1 J  inch  below 
the  level  of  a  line  joining  the  lower  border  of  the  symphysis 
with  the  tip  of  the  coccyx.  The  usual  projection  of  the  pelvic 
floor  is,  therefore,  1|  inch.  Three  canals  pierce  it — viz.,  the 
urethra,  the  vagina,  and  the  rectum  (Fig.  111).  The  central 
canal,  the  vagina,  becomes  enormously  dilated  during  the 
second  stage  of  labour,  and  in  consequence  the  whole  disposi- 
tion of  the  pelvic  floor  is  altered  (Fig.  112).     The  dilatation 


THE  PELVIS 


263 


of  the  vagina  divides  the  pelvic  floor  into  two  sections  :  the 
anterior  section,  lying  in  front  of  the  vagina,  becomes  drawn 
upwards  and  forwards  ;  the  posterior  section,  lying  behind  it, 
becomes  displaced  downwards  and  backwards,  and  the  foetus 
is  expelled  through  the  space  thus  opened  up  between  them. 
The  process  has  been  aptly  likened  by  Berry  Hart  to  the  act 


Pig.  112.— The  Pelvic  Axis.     (Galabin.) 

E,  F.  Conjugate  of  the  brim.  B,  N.  Diagonal  conjugate.  L,  K.  Conjugate  of  the  cavity  (mid). 
N,  M.  Conjugate  of  the  outlet.  O,  P.  Axis  of  the  brim.  Q,  R.  Axis  of  the  cavity. 
A,  B,  C,  D.  The  pelvic  axis.    H,  H.  Horizontal  line.     S,  T.  Vertical  line.     X.  Anus. 

of  passing  through  swing  doors  by  pulling  one  door  towards 
you  and  pushing  the  other  away.  The  upward  displacement 
of  the  anterior  section  is  indicated  by  the  alteration  which 
occurs  in  the  position  of  the  urethra  and  bladder  during  the 
second  stage  of  labour.  During  the  first  stage  it  remains  a 
pelvic  organ,  and  lies  behind  the  symphysis  pubis  (Fig.  99)  ; 
in  the  second  stage  it  becomes  drawn  up  above  the  pubes  into 
the  abdomen,  while  the  urethra  is  correspondingly  elongated 


264 


NORMAL  LABOUR 


(Fig.  100).  The  displacement  of  the  posterior  section  has  been 
described  in  connection  with  the  clinical  phenomena  of 
the  second  stage  of  labour.  The  effects  produced  are  dia- 
grammatically  shown  in  Fig.  112.  The  fourchette  is  now 
the  lowest  part  of  the  pelvic  floor  ;  it  lies  4  inches  below  the 
coccygo-symphysial  level ;  the  projection  of  this  portion  of 
the  pelvic  floor  has  therefore  been  increased  to  4  inches,  and  a 


FiCx.  113.-  The  Fully  Dilated  Parturient  Canal.     (Galabin  and  Blacker.) 

wide  aperture  of  exit  provided  for  the  foetus.  The  effect  of 
this  displacement  is  to  prolong  the  pelvic  canal  by  the  forma- 
tion of  a  tube  composed  solely  of  soft  parts  below  the  level 
of  the  pelvic  outlet  ;  this  prolongation,  like  the  cavity  of 
the  true  pelvis  itself,  has  a  shallow  anterior  wall,  but  deep 
posterior  and  lateral  walls.  Its  relation  to  the  bony  canal 
is  diagrammatically  shown  in  Fig.  113,  from  which  it  will 
be  seen  that  the  axis  of  the  prolongation  forms  a  continua- 


THE   PELVIS 


265 


tion  of  the  axis  of  the  bony  pelvis.  The  path  to  be  followed 
by  the  foetal  head  in  passing  through  the  pelvis  is  accordingly 
represented  in  full  by  the  curved  line  A,  b,  c,  d,  representing 
the  axis  of  the  pelvis  (Fig.  112). 

The  most  important  of  the  structures  which  make  up  the 


Fig.  114. — Foetus  showing  tlie  Normal  Attitude  of  Flexion.     (Barbour. 


pelvic  floor  are  the  pelvic  fascia  and  the  levator  ani  muscle. 
The  former  is  the  visceral  layer  which  springs  from  the  fascia 
clothing  the  lateral  pelvic  wall  at  the  level  of  the  white 
line  which  corresponds  to  the  level  of  the  ischial  spine 
(Fig.  107).  Attached  to  the  lower  surface  of  the  pelvic  fascia 
and  arising  from  it,  are  the  fibres  of  the  levator  ani.    These 


266  NORMAL   LABOUR 

two  structures  form  a  diaphragm  closing  in  the  pelvic  cavity 
below,  inasmuch  as  from  each  side  they  pass  downwards  and 
inwards  towards  the  mesial  plane,  where  they  meet,  and 
where  they  are  pierced  by  three  canals,  the  rectum,  the  vagina, 
and  the  urethra.  Owing  to  the  inclination  of  the  pelvis,  the 
whole  pelvic  floor  (but  especially  the  posterior  section)  also 
slopes  somewhat  forwards  (Fig.  113)  ;  therefore  the  foetal 
head,  when  it  reaches  the  pelvic  floor,  rests  upon  a  sloping, 
not  a  horizontal,  surface,  the  general  direction  of  the  slope 
being  downwards,  forwards,  and  inwards. 

The  effect  of  the  changes  which  occur  in  the  pelvic  floor 
during  the  second  stage  is  greatly  to  stretch  and  often  to 
injure  the  anterior  fibres  of  the  levator  ani  muscle  and 
the  portion  of  the  pelvic  fascia  to  which  it  is  attached.  These 
fibres  arise  from  the  posterior  surface  of  the  symphysis  pubis, 
and  passing  downwards  and  backwards  ensheath  the  walls  of 
the  vagina.  The  great  dilatation  which  the  vaginal  canal 
undergoes,  and  the  extent  to  which  its  posterior  wall  becomes 
elongated,  during  the  passage  of  the  child  through  it,  neces- 
sarily inflicts  a  certain  amount  of  injury  upon  the  muscular 
fibres,  and  in  some  instances  upon  the  fascia  also.  This 
results  later  on  in  prolapse  of  the  vaginal  waUs  and  of  the 
uterus  itself. 

II.  The  Foetus. — Lender  this  heading  we  have  to  consider 
(1)  the  disposition  of  the  foetus  in  utero  ;  (2)  the  size  and 
characters  of  the  foetal  skull  ;  and  (3)  the  protective  action 
of  the  bag  of  fluid  Iq.  which  the  foetus  is  contained. 

(1)  The  Dispositio7i  of  the  Foetus. — Durmg  the  last  weeks 
of  pregnancy  the  head,  trunk,  and  limbs  of  the  foetus  are 
packed  up  into  the  smallest  possible  space  in  a  regular  and 
fairly  constant  arrangement,  which  is  termed  the  foetal 
attitude.  This  is  best  described  as  an  attitude  of  general 
flexion  (Fig.  114),  and  the  study  of  frozen  sections  has 
entirely  removed  this  point  from  the  field  of  speculation. 
The  head  is  flexed  so  that  the  chin  touches  the  anterior 
chest-waU  ;  the  forearms  are  flexed  and  crossed  more  or  less 
symmetrically,  so  that  forearms  and  hands  cover  the  face 
(Fig.  114)  ;  the  thighs  are  fully  flexed  on  the  abdomen,  the 
legs  on  the  thighs,  the  feet  on  the  legs,  the  latter  being 
generally  crossed,  but  sometimes  lying  side  by  side  ;  and 
lastly  the  spine  is  flexed,  the  back  forming  a  distinctly  con- 


\, 


\. 


THE   FCETUS 


267 


vex  surface.  Slight  departures  from  this  Trangement  may 
be  met  with.  Thus  the  forearms  may  he  uiider  the  chin  as 
in  Fig.    1 1 5,  thus  rendering  complete  flexion  of  the  head 


Fig.  115. — Foetus  showing  Deficient  Flexion  of  the  Head  through 
the  Arms  being  undei'neath  the  Chin.     (Barbour.) 


impossible.  All  abnormalities  of  attitude  lead  to  a  certain 
amount  of  difficulty  in  labour.  Any  disturbance  of  this 
attitude  usually  involves  some  departure  from  the  normal 
course  of  labour. 

As  thus  disposed,  the  body  of  the  foetus  forms  an  ovoid 


268 


NORMAL  LABOUR 


mass  the  greatest  width  of  which  corresponds  with  the 
shoulders.  The  dimensions  of  the  ovoid  are  as  follows 
(Fig.  116)- 


Yertico-podalic  diameter  (Y-P) 
Bis-acromial  „         (A.-A) 

Bi-troclianteric        ,,         (T-T) 


9i  to  10    in.  (24  to  25  cm.) 
4|    ,,    (12  cm.) 
4      ,,   (10  cm.) 


The  widest  transverse  diameter  is  across  the  shoulders. 
The   smallest   circumference   of  the   flexed  head  is   about 

11  inches  (27'5  cm.)  ;  the  circum- 
ference of  the  breech,  both  thighs 
being  flexed,  is  about  13  inches 
(32-5  cm.). 

From  this  it  follows  that  the 
foetal  ovoid  will  adapt  itself  most 
easily  to  the  ovoid  shape  of  the 
uterine  cavity  at  term  when  the 
head  lies  below  and  the  breech 
above  ;  the  least  convenient  ar- 
rangement "ttdll  be  that  in  which 
the  foetal  ovoid  hes  across  the 
uteruie  ovoid.  When  the  long 
axes  of  the  foetal  and  uterine 
ovoids  correspond,  the  arrange- 
ment is  called  the  longitudinal  lie  ; 
of  this  there  are  two  varieties — 
(a)  that  in  which  the  head  is 
below,  and  (b)  that  in .  which 
the  breech  is  below.  When  the 
long  axes  do  not  correspond,  the 
arrangement  is  called  the  transverse  or  oblique  lie.  In  over 
96  per  cent,  of  all  labours  the  lie  is  longitudinal  with  the  head 
below  ;  when  this  is  the  case,  the  part  of  the  head  which 
first  enters  the  pelvic  brim  is  in  the  great  majority  of  cases 
the  vertex.  This  arrangement  is  called  in  brief  a  vertex 
presentation,  the  first  part  to  enter  the  brim  being  always 
termed  the  presenting  part.  Presentation  of  the  vertex 
implies  that  the  head  is  fairly  well  flexed,  even  if  the  chin  does 
not  actually  rest  on  the  chest.  If  the  head  is  imperfectly 
flexed  some  other  part  will  present. 

(2)  The  Foetal  Skull. — Since  the  head  presents  in  such  a 


Fig.  116.— The  Normal  Atti 
tude  of  Flexion  (Diagram 
matic).     (Dakin.) 


FCETAL   SKULL 


269 


preponderating  proportion  of  cases,  it  must  be  studied  in 
detail  and  in  relation  to  the  parturient  canal  through  which 
it  has  to  pass. 

The  ossification  of  the  foetal  skull  at  term  is  incomplete, 
especially  in  the  case  of  the  bones  which  compose  the  vault. 
While  those  of  the  base  are  firm  and  incompressible  the 
tabular  bones  of  the  vault  remain  thin  and  pliable,  and  are 
separated  at  their  edges  by  intervals  of  unossified  membrane 
forming  the  sutures  and  the  fontaneUes.  The  vault  of  the 
skull  is  consequently  compressible,  and  in  fact  it  becomes 


Fig.  117.— Side  View  of  the  Foetal  Skull. 

modified  considerably,  both  in  size  and  shape,  by  the  pressure 
to  which  it  is  subjected  during  labour. 

The  sagittal  suture  crosses  the  vault  of  the  skull  in  the 
middle  line,  lying  between  the  two  parietal  bones  (Fig.  118,  6) ; 
in  the  same  plane  in  front  of  the  anterior  fontanelle  runs  the 
frontal  suture,  lying  between  the  two  halves  of  the  frontal 
bone.  The  coronal  suture  separates  the  frontal  from  the 
parietal  bones,  meeting  the  sagittal  and  frontal  sutures  at 
the  anterior  fontanelle  (Fig.  118,  b).  The  lambdoidal  suture 
separates  the  parietal  bones  from  the  tabular  portion  of  the 
occipital  bone  (Fig.  118,  a). 

Four  or  five  fontanelles  exist  in  the  skull  at  term,  but 
pnly  two  of  them  are  of  practical  importance  in  midwifery 


270 


NORMAL   LABOUR 


— viz.,  the  anterior  and  posterior  fontanelles.  The  anterior 
fontanelle  or  bregma  is  an  unequal-sided  lozenge-shaped 
piece  of  undssified  membrane,  lying  in  the  mesial  plane 
between  the  two  frontal  and  the  two  parietal  bones 
(Fig.  118,  h).  Its  angles  are  continuous  with  the  frontal, 
the  sagittal,  and  the  right  and  left  halves  of  the  coronal 
sutures.  The  latter  enter  it  considerably  behind  its  centre. 
It  measures  \\  inches  in  antero-posterior  and  f  inch  in 
transverse  diameter,  and  as  it  lies  a  little  below  the  general 
level  of  the  skull,  it  can  be  felt  on  the  surface  as  a  shallow 
depression.  The  posterior  fontanelle  is  not  as  a  rule  an 
unossified  piece  of  membrane  at  all,  but  a  triangular  depres- 


FlG.  118. — a,  Foetal  Skull  allowing  the  Posterior  Fontanelle. 
h,  Foetal  Skull  showing  the  Anterior  Fontanelle.     (Galabin.) 

sion  produced  by  the  angle  of  the  tabular  portion  of  the 
occipital  bone  being  slightly  depressed  below  the  level 
of  the  posterior  borders  of  the  parietal  bones  with  which  it 
comes  in  contact  (Fig.  118,  a).  This  depression  lies  at  the 
point  of  junction  of  the  sagittal  suture  with  the  right  and 
left  halves  of  the  lambdoidal  suture.  In  a  premature 
foetus,  however,  an  unossified  piece  of  membrane  often 
persists  at  the  posterior  fontanelle. 

These  two  fontanelles  are  of  importance  because  they  can 
be  recognised  by  touch  during  labour,  and  from  them 
valuable  information  can  be  obtained  as  to  the  j)osition  and 
attitude  of  the  foetal  head.  The  anterior  can  be  recognised 
by  its  lozenge  shape,  its  soft  membranous  floor,  and  the 


FCETAL  SKtJLL 


271 


presence  of  four  sutures  running  from  its  angles.  The 
frontal  may  be  distinguished  from  the  sagittal  end  of  this 
fontanelle  by  its  greater  width.  The  posterior  is  triangular 
in  shape,  has  a  hard  floor,  a  raised  edge  (parietal),  and  is 
connected  with  only  three  sutures. 

The  general  shape  of  the  foetal  head  is  that  of  an  ovoid 
with  a  long  antero-posterior  diameter  (Fig.  117).  In  the 
normal  attitude  of  complete  flexion  the  long  diameter  of 
the  head  ovoid  forms  a  very  acute  angle  with  that  of  the 
body  ovoid  ;  when  the  head  lies  midway  between  flexion 
and  extension  the  two  long  diameters  cross  one  another  at 
right  angles  ;  when  the  head  is  fully  extended  the  angle 
formed  is  very  obtuse  and  the  face  becomes  the  lowest  part. 
This  part  of  the  circumference  of  the  head  which  first  comes 
in  contact  with  the  pelvic  brim — i.e.,  the  girdle  of  contact — 
varies  with  the  degree  of  flexion  or  extension  which  may  be 
present,  and  accordingly  the  diameter  of  the  girdle  of  con- 
tact {diameter  of  engagement)  also  varies.  In  passing  from 
the  position  of  complete  flexion  to  that  of  complete  exten- 
sion the  diameters  of  the  successive  girdles  of  contact  are  as 
follows  : 


1 .  Sub  -  occipito  -  bregmatic 

(S.-o.-b.)  (nape  of  neck  to 
centre  of  bregma) 

2.  Sub  -  occipito  -  frontal 

(S.-o.-f.)  (nape  of  neck  to 
anterior  end  of  bregma) 

3.  Occipito-frontal        (O.-f.) 

(occip.  protxiberance  to 
root  of  nose) 

4.  Mento  -  vertical     (M.-v.) 

(point  of  cbin  to  centre 
of  sagittal  suture) 

5.  Sub  -  mento-  vertical 

(S.-m.-v.)  (angle  between 
neck  and  chin  to  centre 
of  sagittal  suture) 

6.  Sub-  mento  -  bregmatic 

(S.-m.-b. )  (angle  between 
neck  and  cbin  to  centre 
of  bresma) 


Length. 
3|  in.  (  9-50  cm.) 


4    in.  (10-00  cm.) 


Presentation. 

Completely      flexed 
vertex 

Incompletely  flexed 
vertex 


4^  in.  (11 '25  cm.)       Extended  vertex 


5^  in.  (13 "7 5  cm.)       Brow  presentation 


4i  in.  (11-25  cm.) 


3|  in.  (  9-50  cm.) 


Incompletely      ex- 
tended face 


Completely  ex- 
tended face 


In  addition  to  the  above,  three  transverse  diameters  of 


272  NORMAL   LABOUR 

the  head  are  of  ijuportance  :  (1)  the  bi-parietal  (3|  inches — 
9'50  cm.),  between  the  two  parietal  eminences  ;  (2)  the  bi- 
temporal (3 J  inches — 8  cm.),  between  the  anterior  ends  of 
the  coronal  suture  ;  (3)  the  bi-mastoid  (3  inches — 7'5  cm.), 
between  the  tips  of  the  mastoid  processes.  The  circum- 
ference of  the  head  varies  hi  different  planes  ;  the  smallest 
circumference  is  that  of  the  sub-occipito-bregmatic  plane, 
which  measures  11  inches. 

It  must  be  recollected  that  all  diameters  which  involve 
the  vault  are  compressible,  and  can  be  reduced  in  length  to  an 
appreciable  extent  during  the  passage  of  the  head  through 
the  pelvis. 

(3)  The  Liquor  Amnii.- — During  the  greater  part  of  the 
process  of  labour  the  foetus  is  protected  from  pressure  by  the 
liquor  amnii  at  every  part  except  the  ghdle  of  contact.  The 
uterine  contractions  do  not  act  directly  upon  the  body  of  the 
foetus  until  labour  is  far  advanced  and  the  liquor  amnii  has 
more  or  less  comjiletely  escaped.  The  lower  pole  of  the 
foetal  envelopes  containing  the  fore-waters  becomes  detached 
from  the  lower  uterme  segment  early  in  labour,  and  is  driven 
down  by  the  contractions  into  the  cervix  in  advance  of  the 
presenting  part  of  the  foetus.  The  mechanical  value  of  this 
bag  of  waters  as  an  aid  to  the  dilatation  of  the  cervix  is  very 
considerable,  on  account  of  its  elasticity  and  its  shape.  "When 
the  cervix  is  dilated  and  the  bag  of  waters  is  consequently 
unsupported,  the  membranes,  as  a  rule,  can  no  longer  resist 
the  strahi  of  the  increased  tension  produced  by  the  uterine 
contractions,  and  rupture  accordingly  takes  place.  The 
membranes  day,  however,  in  some  cases,  rupture  before 
labour  or  earh^  in  the  first  stage  ;  on  the  other  hand,  when 
unusually  strong,  spontaneous  ruptme  may  not  take  place 
at  all,  the  bag  of  waters  appearing  at  the  vulva  during  the 
bnth  of  the  head. 

In  normal  conditions  the  hquor  amnii  is  sterile  ;  it  may, 
however,  become  uifected  during  labour  by  bacteria  intro- 
duced from  without,  or  by  organisms  which  reach  it  through 
the  placenta  from  the  maternal  circulation,  as  in  certain  acute 
Infectious  fevers.  The  former  is,  of  com'se,  greatly  facili- 
tated if  ante-partum  rupture  of  the  membranes  should  occur, 
although  we  also  know,  from  clinical  observation,  that 
bacterial  infection  may  take  place  through  intact  membranes. 


v^ 


FORCES   OF   LABOUR  273 

The  liquor  amnii  may  also  be  fouled  by  meconium  passed 
in  utero  in  conditions  producing  foetal  distress. 

III.  The  Forces  of  Labour. — The  propelling  force  con- 
sists of  muscular  contractions,  aided  possibly  to  an  insignifi- 
cant extent  by  gravity  and  by  the  elastic  recoil  of  certain 
portions  of  the  birth-canal.  The  most  important  muscle  is 
the  uterus  ;  subsidiary  to  it  are  the  diaphragm  and  the 
muscles  of  the  abdominal  wall  ;  those  of  the  arms,  legs,  and 
back  lend  a  certain  amount  of  assistance  in  the  expulsive 
stages. 

The  Parturient  Uterus. — The  changes  which  the  uterine 
muscle  undergoes  during  pregnancy  have  been  already 
described.  At  term  the  wall  of  the  uterus  is  about  \  inch 
in  thickness,  and  the  organ  measures  11^  to  12  inches 
(29  to  30  cm.)  in  length  from  os  externum  to  fundus  (cervix 
1|  to  2  inches — 3-5  to  5  cm.)  ;  the  diameters  of  the  fundus 
itself  are  about  8  to  9  inches  (20  to  22-5  cm.)  transversely 
and  6  inches  (15  cm.)  antero -posteriorly.  At  the  lower 
uterine  segment  the  diameters  are  less,  so  that  the  organ  is 
distinctly  pyriform  or  ovoid  in  shape.  The  internal  os  is 
usually  closed  and  the  cervical  canal  intact  when  labour  sets 
in  (Fig.  97).  The  parturient  uterus  acts  by  intermittent 
contractions,  which  are  limited  to  the^  upper  three-fourths 
of  the  body,  and  which  have  the  effect,  first,  of  dilating  the 
lower  uterine  segment  and  cervix,  and  secondly,  of  expelling 
the  uterine  contents.  The  organ  thus  becomes  differentiated 
during  labour  into  an  upper  active  and  a  lower  passive 
section  ;  this  is  probably  an  essential  step  in  the  process  of 
parturition,  and  invariably  precedes  the  actual  expulsion 
of  the  foetus. 

The  uterine  contractions  of  labour  are  to  be  regarded  as  a 
development  of  the  slight  intermittent  contractions  which 
can  be  recognised  clinically  in  the  gravid  uterus  during  the 
second  half  of  pregnancy.  During  pregnancy  the  patient  is 
unconscious  of  their  presence,  and  they  produce  no  effect 
upon  either  the  cervix  or  the  ovum  ;  when  labour  begins 
they  change  their  characters  and  become  painful.  Through- 
out the  process  they  preserve  their  intermittent  character, 
but  the  intervals  tend  gradually  to  diminish  as  labour 
advances,  until  the  actual  expulsion  of  the  child  through  the 
vulva  may  be  accomplished  by  a  storm  of  powerful  con- 
E.M.  18 


274  NORMAL   LABOUR 

tractions  separated  by  only  slight  intervals.  After  this  their 
intensity  suddenly  falls,  and  the  last  part  of  the  process — 
viz.,  the  separation  and  expulsion  of  the  after-birth — is 
accompanied  only  by  a  few  comparatively  feeble  contrac- 
tions. They  are  of  course  involuntary  ;  in  animals  they  are 
peristaltic,  but  clinically  this  is  not  observable  in  women. 
It  may  be  surmised  that  the  driving  force  of  the  uterus 
resides  chiefly  in  the  longitudinal  fibres,  contraction  of  which 
will  tend  to  approximate  fundus  to  cervix. 

With  each  contraction  a  change  in  the  shape  and  position 
of  the  uterus  occurs.  When  at  rest  the  organ  lies  moulded 
upon  the  vertebral  column  (Fig.  46) ;  during  the  contraction 
the  fundus  is  thrown  forward  towards  the  abdominal  wall, 
and  the  whole  organ  becomes  rigid  and  erect.  The  efEect  of 
this  change  of  position  will  be  to  make  the  long  axis  of  the 
uterus  correspond  more  closely  with  the  line  of  the  axis  of 
the  pelvic  brim  (Fig.  100). 

As  labour  advances  two  other  important  changes  are 
brought  about  in  the  parturient  uterus — viz.,  (1)  dilatation  of 
the  lower  uterine  segment  and  cervix  ;  (2)  retraction  of  the 
uterine  wall  above  this  level.  The  exact  nature  of  these 
changes  has  been  the  subject  of  acute  controversy  since  the 
study  of  the  anatomy  of  labour  by  frozen  sections  began, 
and  even  now  unanimity  of  opinion  has  not  been  reached. 
In  the  following  description  the  work  of  Barbour  has  been 
followed. 

(1)  Lower  Uterine  Segment  and  Cervix. — The  condition  of 
the  cervical  canal  before  labour  commences  has  been  already 
described  ;  it  measures  from  IJ  to  2  inches  (3  to  5  cm.) 
from  OS  externum  to  os  internum,  and  the  lower  uterine 
segment,  corresponding  to  about  the  lower  one-fourth  of 
the  total  uterine  cavity  (Barbour),  has  the  shape  of  a 
hemisphere. 

The  condition  of  these  parts  at  the  end  of  the  second 
stage  of  labour  is  shown  in  Fig.  119.  The  lower  segment  has 
now  been  converted  from  a  hemisphere  into  a  cylinder,  and 
forms  with  the  dilated  cervix  a  single  wide  canal.  The 
position  of  the  os  iaternum  is  very  difficult  to  determme 
except  by  recognition  of  the  upper  limit  of  the  characteristic 
cervical  mucous  membrane.  But  the  conclusions  arrived  at 
by  different  observers  upon  this  point  are  very  divergent, 


LOWER   UTERINE   SEGMENT 


275 


and  it  appears  probable  that  the  proportion  of  the  dilated 
part  which  corresponds  to  the  cervix  is  variable.  At  the 
upper  limit  of  this  dilated  part  an  abrupt  change  in  the 
thickness  of  the  uterine  wall  takes  place,  producing  a  raised 
ridge  on  the  inner  wall  in  the  form  of  an  irregular  ring  which 
varies  a  little  in  level  in  different  parts.  This  ring  is 
variously  known  as  the  retraction  ring  (Barbour),  the  con- 


Placenta 


ji  separation  of 
-•J    membranes 


Os  externum 


Fig.  119. 


-The  Birth-Canal  towards  the  end  of  the  Second  Stage  of 
Normal  Labour.     (Barbour.) 


traction  ring  (Schroeder),  BandVs  ring,  Barnes's  ring,  &c. 
By  some  observers  this  ring  was  regarded  as  representing  the 
internal  os,  the  whole  of  the  dilated  part  below  it  was  con- 
sidered to  be  cervix,  and  the  existence  of  a  lower  uterine 
segment,  distinct  from  the  cervix,  was  denied.  The  work  of 
Schroeder,  Barbour,  and  Von  Franque,  however,  appeared 
until  recently  to  have  satisfied  most  observers  that  the  upper 
portion  of  the  dilated  part  comes  from  the  uterine  body,  not 

18 — 2 


276  NOBiVlAL   LABOUR 

from  the  cervix.  But  this  view  has  now  again  been  chal- 
lenged by  Bumm  and  Blnmreich,  so  that  it  is  evident  that 
controversy  upon  this  matter  is  not  yet  over. 

The  wall  of  the  lower  segment  and  cervix  measures  on  an 
average  one-tenth  of  an  inch  (25  mm.)  in  thicknesSj  while 
above  the  lower  segment  the  uterine  wall  varies  from  one- 
half  to  a-quarter  of  an  inch  (l*2o  to  0*62  cm.)  in  thickness, 
being  least  at  the  placental  site.  Lower  segment  and  cervix 
together  now  measure  m  length  3|  inches  (9  cm.)  on  the 
anterior  and  2|  inches  (6"5  cm.)  on  the  posterior  wall.  From 
examination  of  a  number  of  frozen  sections  it  appears  that 
the  average  length  of  the  uterus  from  fundus  to  os  externum 
is  10  to  10|  inches  (25  to  26  cm.)  towards  the  end  of  the 
second  stage  of  labour — i.e.,  before  the  explusion  of  the 
foetus.  The  total  length  of  the  uterus  has  therefore  at  this 
period  been  reduced  by  about  1 J  inch  (4  cm.).  The  diameter 
of  both  lower  segment  and  cervix  is  now  about  4  inches 
(10  cm.).  The  'posterior  vaginal  wall  is  greatly  elongated — 
7  inches  (18  cm.)  in  Tig.  119 — and  somewhat  thinned,  while 
the  anterior  wall  is  practically  unaltered  m  length. 

(2)  The  Retracting  Uterine  Wall. — The  line  of  abrupt 
transition  from  the  lower  segment  to  the  uterine  body  above 
it  represents  the  hne  of  physiological  differentiation  of  the 
uterus  into  an  upper  active  and  a  lower  passive  zone.  The 
uterine  contractions  occur  in  the  active  portion  only,  the 
rdle  of  the  other  being  entirely  passive,  as  is  sho\^Ti  by  the 
marked  degree  of  dilatation  and  thinning  which  it  has 
undergone.  The  reduction  in  length  of  the  active  portion 
and  the  increased  thickness  of  its  walls  represent,  however, 
another  phase  of  its  activity — viz.,  retraction.  The  dis- 
tinction between  contraction  and  retraction  of  muscle  is 
simple  :  contraction  is  a  temporary  reduction  in  length  of 
the  muscle,  which  may  be  succeeded  by  complete  elongation 
to  its  original  length  ;  but  retraction  signifies  permanent 
shortening,  complete  elongation  bemg  impossible  so  long 
as  the  retraction  lasts.  Li  the  case  of  a  muscle  contractmg 
intermittently,  a  certain  amount  of  retraction  may  accom- 
pany each  contraction,  unless,  when  the  contraction  passes 
off,  it  is  agam  elongated  to  the  full  extent.  Shortenmg  from 
retraction  will  thus  become  progressive.  This  is  what 
occurs  in  the  uterus  during  the  second  stage  of  labour  :    as 


UTERINE    RETRACTION  277 

the  foetus  is  driven  with  each  contraction  lower  down  into 
the  pelvl,_,  a  certain  amount  of  the  advance  is  made  good 
by  retraction.  If  retraction  did  not  occur,  then  the  elastic 
recoil  of  the  soft  structures  composing  the  walls  of  the 
undilated  parts  of  the  canal  would  act  through  the  lower 
pole  of  the  ovum  upon  the  uterine  muscle  and  completely 
elongate  it,  so  that  the  foetus  would  return  to  the  position  it 
occupied  before  the  contraction  occurred.  Advance  under 
such  circumstances  would  of  course  be  much  delayed. 
Retraction,  therefore,  maintains  a  certain  amount  of  the 
progress  made  during  each  contraction.  It  will  also  be 
noticed  that  retraction  must  cause  some  diminution  in  the 
superficial  area  of  the  uterine  wall  ;  this  is  of  importance 
in  regard  to  the  mechanism  of  separation  of  the  after-birth. 
In  cases  of  obstructed  labour  retraction  becomes  greatly 
exaggerated,  so  that  the  retraction  ring  forms  a  ridge  which 
can  be  recognised  by  palpation  through  the  abdominal  walls 
(see  p.  463).  In  cases  of  unobstructed  labour  its  presence 
cannot  be  recognised  by  clinical  observation. 

Dilatation  of  the  lower  segment  and  cervix  is  brought 
about  by  the  uterine  contractions  acting  either  through  the 
bag  of  waters  or  directly  through  the  presenting  part.  The 
conical  shape  and  elastic  consistence  of  the  bag  will  enable  it 
to  dilate  the  canal  equally,  acting  as  a  '  fluid  wedge.'  The 
presenting  part  forms  a  much  less  efficient  dilator,  partly 
because  it  is  inelastic,  partly  because  it  does  not  adapt  itself 
so  readily  in  shape  to  the  dilating  canal.  A  certain  relation- 
ship normally  exists  between  active  contractions  of  the  body 
of  the  uterus  and  dilatation  of  the  cervix  ;  whenever  active 
contractions  occur  the  cervix  at  once  begins  to  open  ;  and, 
conversely,  if  the  cervix  is  artificially  dilated,  active  con- 
tractions will  be  induced  in  the  body  of  the  uterus.  This 
physiological  relationship  has  been  termed  the  'polarity  of 
the  uterus.  It  has  also  been  suggested  that  the  longitudinal 
fibres  of  the  outer  muscular  wall,  when  contracting,  tend  to 
pull  the  cervix  upwards  over  the  presenting  part,  and  thus 
to  some  extent  assist  the  process  of  dilatation. 

Anything  interfering  with  the  normal  mechanism,  such  as 
inefficient  contractions,  premature  rupture  of  the  mem- 
branes, or  structural  alterations  in  the  cervix,  will  prevent 
or  delay  the  occurrence  of  dilatation. 


278  NORMAL   LABOUR 

The  Labour  Centre. — It  is  possible  that  the  process  of 
parturition  is  mider  the  control  of  a  special  centre  in  the 
lumbar  enlargement  of  the  spinal  cord,  for  it  is  well  known 
that  in  certain  animals  powerful  uterine  contractions  can  be 
induced  by  experimental  stimulation  of  the  lumbar  enlarge- 
ment. Also,  women  suffering  from  paraplegia  due  to  injury 
or  disease  affecting  the  cord  above  the  level  of  the  lumbar 
enlargement,  may  pass  through  an  easy  and  rapid  labour, 
which  is,  of  course,  pauiless.  These  facts,  however,  do  not 
suffice  to  prove  the  existence  of  a  labour  centre  ;  for  large 
sympathetic  gangha  are  found  at  the  sides  of  the  uterus, 
between  the  layers  of  the  broad  Hgament,  which  may,  by 
automatic  action,  themselves  induce  contractions.  Cer- 
tainly in  some  animals  rhj'thmic  contractions  of  the  uterme 
muscle  may  be  induced  by  stimulating  these  ganglia,  or 
the  uterus  maj^  be  made  to  contract  after  its  removal  from 
the  body  in  the  same  manner.  In  the  human  subject, 
however,  the  balance  of  probability  is  in  favour  of  the 
existence  of  a  centre  in  the  cord. 

The  manner  in  which  the  nerve  centres,  whether  j)eri- 
pheral  or  spinal,  are  so  excited  as  to  initiate  the  process  of 
labour  is  unknown.  The  onset  of  labour  is  no  doubt  due  in 
some  way  to  stimulation  of  these  centres,  and  although  many 
hypotheses  have  been  advanced,  the  fact  remains  that  there 
is  little  or  no  evidence  in  favour  of  any  of  them,  and  accord- 
ingly they  need  not  be  discussed.  The  progressive  increase 
in  the  activity  of  these  centres  when  once  labour  has  com- 
menced may  be  simply  explained  by  peripheral  stimuli 
coming  from  the  uterine  nerves,  which  are  stretched  by 
dilatation  or  compressed  by  muscular  contraction. 

General  Effects  of  Labour. — During  a  uterine  contraction 
it  is  noticed  that  the  foetal  heart  beats  more  slowly  and  more 
feebly,  but  quickly  recovers  its  normal  action  as  the  pain 
passes  off.  The  uterine  souffle  becomes  louder  at  the  com- 
mencement of  a  contraction,  then  rapidly  diminishes,  and 
becomes  cpiite  inaudible  at  the  acme  of  the  contraction. 
The  mother's  pulse  is  quickened  during  the  contractions. 
The  amount  of  blood  lost  during  normal  labour  averages 
about  10  ounces,  more  than  half  of  which  accompanies  the 
placenta.  In  Avomen  of  average  phj^sique,  the  general 
effects  of  normal  labour  are  usually  those  of  physical  exhaus- 


\ 


V 


THIRD   STAGE  279 

tion,  corresponding  with  the  length  and  severity  ol  ohe  labour 
pains.  The  temperature  may  be  elevated  one  or  two  degrees 
and  the  pulse  a  little  accelerated — ten  to  fifteen  beats  above 
the  normal.  In  women  of  less  than  average  physique,  nor- 
mal labour  sometimes  leads  to  alarming  surgical  shock, 
accompanied  by  pallor,  coldness  of  the  body  surface, 
especially  of  the  limbs,  rapid  and  feeble  pulse,  and  a  sub- 
normal temperature  ;  sometimes  there  is  loss  of  conscious- 
ness. There  may  be  no  unusual  haemorrhage  in  such  cases. 
Treatment  by  the  application  of  heat  to  the  body,  the  rectal 
injection  of  warm  saline  solution,  and  the  deep  intra- 
muscular injection  of  pituitrin  is  usually  successful.  The 
author  has,  however,  seen  two  cases  in  which  the  symptoms 
were  so  alarming  that  intra-venous  saline  transfusion  was 
resorted  to.  A  certain  number  of  cases  which  terminated 
fatally  have  been  recorded. 

Acute  dilatation  of  the  heart  sometimes  occurs  after 
labour  in  persons  not  previously  known  to  suffer  from  heart 
lesions.  In  all  probability  some  cardiac  defect  has  passed 
unobserved  in  such  cases.  A  trace  of  albumen  is  frequently 
found  in  the  urine  of  perfectly  healthy  women  during  normal 
labour  ;  this  is  especially  common  in  primiparse. 

Anatomy  and  Physiology  of  the  Third  Stage 
of  Labour 

It  has  now  been  demonstrated  by  the  study  of  frozen 
sections  that  separation  of  the  placenta  and  the  greater  part 
of  the  membranes  does  not  occur  until  the  third  stage  (see 
Fig.  119).  At  the  beginning  of  this  stage  the  uterus  measures 
about  8  inches  (20  cm.)  vertically  and  4  inches  (10  cm.) 
antero-posteriorly  ;  its  wall  is  greatly  thickened  at  all  parts 
except  the  placental  site.  The  uterine  cavity  is  so  reduced 
that  the  placenta  practically  fills  it.  The  membranes  are 
still  attached  to  the  uterine  wall  except  in  the  lower  segment, 
from  which  they  become  detached  during  the  stage  of  dilata- 
tion, while  the  placenta  is  folded  and  much  reduced  in  size. 
The  plane  of  cleavage  runs  through  the  cavernous  layer  of 
the  decidua  basalis  (Fig.  17),  the  deepest  part  of  which 
remains  attached  to  the  uterine  wall. 

It  is,  however,  quite  clear  that  in  the  great  majority  of 


280 


NORMAL   LABOUR 


cases  the  placenta  is  delivered  in  one  of  the  following  two 
ways  :  (1)  In  some  instances  a  portion  of  the  placenta  near 
its  centre  becomes  separated,  and  haemorrhage  from  the  torn 
uterine  sinuses  occurs  at  that  spot.  As  more  blood  is  effused, 
an  increase  in  the  area  of  sejDaration  occurs  by  the  formation 
of  a  retro "iDlacental  blood  clot.  The  centre  of  the  jDlacenta  is 
thus  forced  down  towards  the  cervix,  where  its  foetal  surface, 


Fig.  120.— Separation  of  the  Placenta  by  foiniation  of 
Eetro-placental  Clot.     Diagrammatic.     (Varnier.) 

with  the  umbihcal  cord  attached,  presents  ;  it  then  passes 
through  the  aperture  in  the  membranes  formed  by  the 
passage  of  the  foetus,  and  enters  the  vagma,  pulling  the 
membranes  off  behind  it  and  tm-ning  them  mside  out.  This 
mode  of  separation,  which  can  frequently  be  observed,  was 
first  described  by  Schultze.  It  is  diagrammaticaUy  repre- 
sented in  Fig.  120,  and  is  shown  ad  naturam  in  Fig.  121,  in  a 
uterus  removed  from  the  body  after  death.     (2)  The  second 


THIRD   STAGE 


281 


iJ  n  ATTACH  ED 
"^    'I'MEMBRAHES 


RETRACTION 
RING 


mode  of  separation  of  the  placenta  is  illustrated  in  Figs.  122 
and  123,  and  was  first  clearly  described  by  Matthews  Duncan. 
Detachment  com- 
mences at  the 
lower  pole,  which 
is  not  subjected 
to  the  same 
amount  of  com- 
pression as  the 
remainder  of  the 
placenta,  on  ac- 
count of  the  patu- 
lous condition  of 
the  cervical  canal, 
and  the  whole 
organ  is  gradually 
forced  into  the 
cervix,  the  Upper 
pole  being  the  last 
to  leave  the  ute- 
rine cavity.  The 
edge  or  the  ute- 
rine surface  of  the 
placenta  presents 
in  this  case. 

The  mechan- 
ism of  the  latter 
mode  of  separa- 
tion has  been 
explained  by  Bar- 
bour as  follows  : 
When  retraction 
occurs  after  the 
expulsion  of  the 
child,  the  area  of 
the  uterine  sur- 
face is  much  di- 
minished ;  the  placenta,  being  an  inelastic  organ,  cannot 
follow  this  diminution  to  any  great  extent,  and  therefore 
becomes  detached,  the  uterine  wall  tearing  itself  away 
from  the  placenta.     This  process  begins  at  the  lower  pole, 


BLADDER. 


Fig 


UMBILICAL   CORD 


121.— Uterus  in  the  Third  Stage.  The 
placenta  is  inverted  and  detached,  lying  in 
the  lower  segment.  It  is  held  up  by  adhesion 
of  the  membranes  to  the  fundus.  A  small 
retro-placental  clot  has  been  formed.  (Bar- 
bour's Anatomy  of  Labour.) 


282 


NORMAL   LABOUR 


because  there  the  edge  is  entirely  unsupported.  Separation, 
thus  commenced,  is  advanced  by  each  recurring  contraction, 
and  haemorrhage  plays  no  part  in  this  mechanism.  In  the 
case  of  the  first-mentioned  mode  of  separation,  on  the  other 
hand,  relaxation  of  the  uterus  at  the  placental  site,  leading 
to  effusion  of  blood,  is  probably  the  initiai  factor  in  its  pro- 


Bare  portion  of 
placental  site 


Fig.  122. — Separation  of  the  Placenta  from  below  upwards, 
matic.     (Bumm.) 


Diagram- 


duction  ;  this  mode  of  separation  will  therefore  be  met  with 
when  retraction  in  the  third  stage  is  inadequate.  It  has  been 
suggested  that  in  cases  of  fundal  insertion  of  the  placenta, 
the  same  result  may  occur  without  haemorrhage  ;  the  central 
portion  of  the  placenta,  being  then  unsupported,  becomes 
first  detached  by  retraction  and  then  driven  downwards  by 
contractions,  thus  causing  the  foetal  surface  to  present  in  the 
cervix. 


\, 


\. 


THIRD   STAGE 


283 


The  separated  placenta  is  expelled  through  the  cervix, 
vagina,  and  vulva  mainly  by  the  action  of  the  accessory 


PLACEHTAL 
5ITE 


■PLACEHTAL  3ITE 
!\l^  \  5LI6HT  INVERSION' 


MEMBRANE 
'■^TIACHED 


PLACENrA 
/DET/ICHED 


Fig.  123.— Uterus  m  the  Third  Stage.  The  placenta  presents  by  its 
edge,  and  is  adherent  at  one  point  to  the  uterine  wall  producino- 
a  partial  inversion.  An  enormous  retro-placental  clot  has  been 
formed  which  was  the  cause  of  death.  (Barbour's  Anatomy  of 
Labour. ) 

muscles  ;   uterine  contractions  are  at  this  stage  too  feeble  to 
play  any  important  part  in  the  process  of  expulsion. 

From   statistics   of   the   Rotunda   Hospital,    Dublin,   it 


284 


NORMAL  LABOUR 


appears  that  the  placenta  separates  by  the  Schultze  method 
much  more  commonly  than  by  the  other,  the  proportions 
being  about  83  to  17  per  cent.  It  also  appears  that  the 
former  mechanism  is  the  more  favourable,  for  the  membranes 
were  found  to  be  incomplete  three  times  more  often  with  the 
Matthews  Duncan  than  with  the  Schultze  mechanism. 


The  Mechanism  of  Normal  Labour 

In  this  section  will  be  described  the  effects  produced  by 
the  expulsive  forces  upon  the  ovum,  and  the  manner  in  which 

the  process  of  ex- 
pulsion is  accom- 
plished. 

First  and  Second 
Stages. — It  will  be 
understood  that 
during  the  greater 
part  of  the  process 
of  labour  the  uterine 
contractions  do  not 
act  directly  upon 
the  body  of  the  foe- 
tus, for  the  latter  is 
completely  protec- 
ted by  the  amniotic 
fluid.  Pressure  is 
transmitted  to  the 
foetus  only  through 
this  fluid  covermg, 
and  smce  pressure 
is  transmitted  by 
a  fluid  medium 
equally  in  all  direc- 
tions, the  effect 
must  be  mainly  of 
the  nature  of  general  compression  by  increase  of  intra-uterine 
tension  {general  or  indirect  intra-uterine  pressure)  (Fig.  124). 
In  this  way  an  expulsive  action  -^dll,  however,  be  exerted 
upon  the  complete  ovum  (membranes  unruptured),  causing 
it  to  protrude  through  the  dilating  cervix,  and  in  some  cases 


Fig.  124. — General  or  Indirect  lutra-iiterine 
Pressure.     (Dakin.) 

Tlie  arrows  indicate  the  direction  of  the  force  exerted  by 
the  contracting  uterus. 


A 
MECHANISM 


285 


an  unruptured  ovum  may  be  thus  completely  expelled  from 
the  uterus  ;  but  here  the  expulsive  forces  nevsr  act  directly 
upon  the  body  of  the.  foetus  at  all.  While  the  membranes 
remain  intact,  or  when  sufficient  liquor  amnii  is  retained,  it 
follows  that  no  effects  injurious  to  the  foetus  can  be  produced. 
The  direction  of  the  advance  at  this  stage  must  be  that  of 
least  resistance — viz.,  through  the  expanding  cervix.  This 
direction  will  be  represented  by  a  line  drawn  at  right-angles 
to  the  plane  of  the  internal  os^ — the  axis  of  the  internal  os. 
When  the  uterus  is  made  erect  by  contraction,  and  there  is 
only  slight  lateral  obliquity,  the  axis  of  the  uterus  and  the 
axis  of  the  internal  os  are 
practically  identical,  and 
correspond  with  the  axis  of 
the  pelvic  brim. 

When  the  membranes 
have  ruptured  and  the 
greater  part  of  the  liquor 
amnii  has  escaped — i.e.,  to- 
wards the  end  of  the  second 
stage  of  labour — the  con- 
tracting uterine  wall  comes 
down  upon  the  body  of  the 
foetus,  exerting  pressure  di- 
rectly upon  it  {direct  intra- 
uterine pressure)  (Fig.  125). 
The  driving  force  now  acts 
upon  the  breech,  and  the 
line  of  advance  will  be  the 
line  of  the  foetal  axis  ;  this 
corresponds  under  normal 
conditions  to  the  axis  of  the  pelvic  inlet.  The  term,  fcetal-axis- 
pressure  is  often  applied  to  the  uterine  force  at  this  stage. 
Force  thus  exerted  upon  the  trunk  of  the  foetus,  when  the 
head  is  in  the  pelvic  cavity,  will  cause  the  head  to  advance 
in  the  direction  of  that  part  of  the  pelvic  axis  to  which  it 
corresponds  at  the  time.  It  will  be  clear  that  prolonged 
pressure  in  these  circumstances  may  produce  injurious  effects 
through  direct  compression  of  the  body  of  the  foetus,  the 
placenta,  or  the  cord. 

In  normal  labour  the  progress  of  the  foetus  through  the 


Fig.  125. — Direct  Intra-uterine,  or 
Foetal-Axis-Pressure.     (Dakin.) 


286 


NOR]MAL   LABOUR 


birth-canal  is  watched  by  observing  the  advance  of  the  foetal 
head  ;  the  relation  of  the  head  to  the  pelvic  brim  at  the 
commencement  of  labour  is  therefore  of  great  importance. 
It  has  already  been  stated  that  the  vertex  presents  in  96  per 
per  cent,  of  all  labours.  This  predominant  frequency  is  due 
to  two  causes  :  ( 1 )  under  normal  conditions  the  foetal  ovoid 
a^dapts  itself  best  to  the  shape  of  the  uterus  when  the  head 
lies  below,  the  breech  above  ;   (2)  the  centre  of  gravitj^  of  the 


Fig.  126. — ^Vertex  Presentation.    First  Position  (L.O.A.). 
(Faraboeuf  and  Yarnier.) 

foetus  lies  nearer  the  head  than  the  breech,  therefore  the 
foetus  will,  if  undisturbed,  float  in  the  hquor  amnii  vrith  the 
head  below. 

With  the  vertex  presenting,  the  foetus  may  occupy  four 
different  positions  :  the  back  may  be  anterior  and  directed 
either  to  the  left  or  right  of  the  mother  ;  or  the  back  may  be 
posterior  and  directed  either  to  the  right  or  left  of  the  mother. 
The  part  of  the  vertex  which  corresponds  with  and  indicates 
the  position  of  the  back  is,  of  course,  the  occiput  ;  this  is 
termed  the  denominator  of  the  positions  which  are  named 
from  it  thus  (Mgs.  126  to  129)  : 


VERTEX   POSITIOJ^S 


287 


1st  position 
2iid       „ 
3rd       ,, 
4tli       „ 


Left  occipito-anterior  .  .  L.O.A. 

Eight  occipito-anterior  .  .  E.O.A. 

Eight  occipito-posterior  .  .  E.O.P. 

Left  occipito-posterior  .  .  L.O.P. 


The  term  position  thus  indicates  the  relation  of  the  back  of 
the  foetus  to  the  mother,  and  it  will  be  found  that  in  all  kinds 
of  presentation  the  four  positions  correspond.  In  the  first 
and  third  positions  the  diameter  of  engagement  of  the  head 
roughly  corresponds  with  the  right  oblique  diameter  of  the 


Fig.  127. — Vertex  Presentation.     Second  Position  (E.O.A.). 
(Faraboeuf  and  Varnier.) 

pelvic  brim  ;    in  the  secon<i   and  fourth  positions   it  corre- 
sponds with  the  left  oblique. 

The  frequency  of  the  various  positions  of  the  vertex  in 
earlier  editions  of  this  work  was  stated  as  follows  : 


Eight  oblique  diameter    .  94% 


1st  position  . 

•  74%- 

2nd      ,, 

.     5%- 

3rd       „ 

.  20% 

4th 

.     1% 

Left 


6% 


The  annual  reports  issued  by  Queen  Charlotte's  Lying-in 
Hospital  contain  statistics  of  position  observed  in  the  large 


288 


^^ORMAL   LABOUR 


number  of  cases  delivered  at  that  institution,  and  these 
statistics  give  quite  different  results.  Calculated  from  a 
series  of  10,000  consecutive  cases  the  percentages  of  fre- 
quency are  as  follows  : 


Eight  oblique  diameter    .  67' 1% 


1st  position  . 

.  53-1%- 

2nd      „ 

.  21-4%. 

3rd       „ 

.   14-0% 

4tli       „ 

.   11-5% 

Left 


32-9% 


The  reports  show  a  remarkable  similarity  in  the  proportions 


Fig.  128.— Vertex  Presentation.     Third  Position  (E.O.P.). 
(Faraboeuf  and  Varnier.) 

met  with  in  each  year,  and  the^e  figures  may  probably  be 
considered  more  accurate  than  the  older  statistics  which 
were  given  on  the  authority  of  Nagele.  Although  differences 
of  opinion  as  to  the  exact  proportions  may  be  held,  it  is 
now  generally  agreed  that  the  first  is  the  most  frequent  and 
the  fourth  the  rarest  ;  the  second  and  third  being  more 
nearly  equal  in  frequency. 

From  this  it  will  be  seen  that  the  vertex  engages  in  the 
right  obhque  diameter  much  oftener  than  in  the  left  ;  this  is 
mainly  due  to  the  fact  that  the  left  oblique  is  encroached 
upon  by  the  presence  of  the  sigmoid  flexure  and  rectum,  and 


VERTEX  POSITIONS 


therefore  does  not  accommodate  the  head  so  well  as_its  fellow. 
Again,  the  first  position  is  three  to  four  times  more  frequent 
than  the  third  ;  this  is  to  be  accounted  for  by  the  fact  that 
the  foetus  lies  more  easily  in  the  uterus  when  the  back  is 
anterior  than  when  it  is  posterior.  In  the  latter  the  con- 
vexity of  the  foetal  spine  is  opposed  to  the  convexity  of  the 
maternal  lumbar  vertebrae,  while  in  the  former  the  ventral 
aspect  of  the  foetus  adapts  itself  easily  to  the  curve  of 
the  spinal  column.     In  the  fourth  position,  the  rarest,  the 


Fig.  129.- 


-Vertex  Presentation.     Fourth  Position  (L.O.P.). 
(Faraboeuf  and  Varnier.) 


conditions  are  the  least  favourable — viz.,  engagement  in  the 
left  oblique  diameter,  and  posterior  position  of  the  back. 
As  we  shall  see,  the  posterior  position  of  the  back  is  also  apt 
to  cause  some  disturbance  of  the  normal  foetal  attitude  of 
flexion. 

The  study  of  frozen  sections  has  proved  that  when  the 
vertex  engages  in  the  pelvic  brim,  owing  to  the  lateral 
inclination  of  the  head  and  to  other  causes,  one  parietal  bone 
frequently  lies  at  a  lower  level  than  the  other  ;  as  a  result 
the  sagittal  suture  does  not  correspond  precisely  to  the 
oblique  diameter,  but  lies  either  in  front  of  or  behind  it. 
This  is  known  as  asynclitism  or  parietal  obliquity.     Usually 

E.M.  19 


290  NORMAL  LABOUR 

the  head  inclines  to  the  posterior  shoulder,  the  anterior 
parietal  bone  is  below  the  posterior,  and  the  sagittal  suture 
nearer  the  promontory  than  the  symphysis  {anterior  asyn- 
clitism, anterior  'parietal  obliquity)  ;  sometimes,  however,  the 
sagittal  suture  lies  nearer  the  symphysis  than  the  promon- 
tory {posterior  asynclitism,  posterior  parietal  obliquity).  The 
former  is  found  chiefly  in  multiparae,  the  latter  in  primiparse, 
the  reason  being  that  in  primiparse  the  relatively  tense 
abdominal  walls  tend  to  keep  the  uterus  back  and  so  prevent 
the  body  of  the  foetus  from  coming  forward  into  the  line  of 
the  axis  of  the  brim  ;  accordingly,  when  the  head  enters  the 
brim  the  posterior  parietal  bone  is  lower  than  the  anterior 
(Fig.  130,  {a)  and  (&)  ).  Sectional  anatomy  has  shown  that  in 
some  cases  (about  25  per  cent.)  this  lateral  inclination  is 
absent,  and  the  sagittal  suture  corresponds  to  the  oblique 
diameter  of  the  pelvis.  It  is  probable  that  under  normal 
conditions  asynclitism  is  corrected  very  early  in  labour. 

The  relation  of  the  head  to  the  pelvis  at  the  onset  of 
labour  in  the  four  positions  of  the  vertex  as  it  appears  when 
viewed  through  the  outlet  is  shown  in  Figs.  131  to  134.  It 
will  be  seen  that  the  sagittal  suture  roughly  corresponds  to 
one  of  the  oblique  diameters,  but  may  He  a  little  in  front  or 
behind  it  as  asynclitism  is  more  or  less  pronounced.  At  one 
end  of  the  suture  lies  the  anterior  fontanelle,  at  the  other  end 
the  posterior  fontaneUe.  If  the  head  is  weU  flexed,  the  pos- 
terior fontanelle  is  lower  than  the  anterior  ;  if  the  head  is 
imperfectly  flexed,  this  will  not  be  the  case.  These  points 
will  again  arise  in  connection  with  the  diagnosis  of  position. 

In  passing  through  the  pelvis,  the  foetus,  in  addition 
to  following  the  curved  line  of  the  pelvic  axis,  describes  a 
certain  definite  series  of  movements  which  alter  its  relations 
to  the  pelvic  canal.  The  valuable  information  obtained  in 
recent  years  by  the  study  of  frozen  sections  of  women  who 
have  died  in  labour  has  made  it  necessary  to  modify  certain 
of  the  older  views  regarding  the  nature  and  causation  of  these 
movements.  It  is  customary  to  describe  them  as  movements 
of  the  head,  but  in  reahty  the  head  is  only  the  index  ; 
external  rotation  is  essentially  a  movement  of  the  trunk,  and 
it  is  probable,  as  we  shall  see,  that  the  same  is  also  true  of 
flexion  and  extension. 

It  will,  of  course,  be  understood  that  throughout  the  first 


VERTEX  POSITIONS 


291 


Fig.  130  (a).— Anterior  Asynclitism;  Nagele's  Obliquity.     (Bumm.) 

The  trunk  lies  away  fiom  tlie  maternal  spine. 


Fig.  130  (b). — Posterior  Asynclitism.     (Bumm.) 

The  trunk  lies  close  to  the  maternal  spine. 

19—2 


292 


NORMAL  LABOUR 


Pig.  131. — First  Position  of  the  Vertex  (L.O.A.),  Anterior  Asynclitism. 

and  second  stages  of  labour  there  is  a  more  or  less  continuous 
movement  of  descent.  Accompanying  tliis,  four  other 
movements  are  described — viz.  :  (I.)  Flexion  ;  (II.)  Internal 
notation  ;  (III.)  Extension  ;  (IV.)  Restitution  and  External 
Rotation. 

I.     Flexion. — Sectional  anatomy  has  shoTvn  that  under 
normal  conditions  the  head,  as  a  rule,  is  flexed  before  labour 


Fig.  132.— Second  Position  of  the  A'ertex  (E.O.A.). 


MECHANISM 


293 


Fig.  133.— Third  Position  of  the  Vertex  (E.O.P.).     Head  fairly 
well  flexed. 

begins.  The  degree  of  flexion  is,  however,  subject  to  a  shght 
variation,  even  under  normal  conditions  ;  when  fully  flexed 
the  chin  is  in  contact  with  the  chest,  but  this  may  be  modi- 
fied by  an  unusually  high  position  of  the  arms  (Fig.  115),  or 
by  other  causes.  Flexion  therefore  is  an  attitude,  not  a 
movement,  and  the  old  view  that  it  was  normally  produced 
during  labour  must  be  abandoned.     Disturbances  of  the 


Pig.  134. — Pourth  Position  of  the  Vertex  (L.O.P.),  Anterior  Asynclitism. 
Incomplete  Plexion. 


294 


NORMAL  LABOUR 


normal  foetal  attitude  of  flexion  at  the  onset  of  labour  are, 
however,  not  uncommon,  causing  the  head  to  enter  the  brim 
in  an  attitude  of  deficient  flexion  or  of  extension.  During 
its  passage  through  the  pelvis  it  may  then  become  flexed, 
and  the  mechanism  of  the  process  may  therefore  be  briefly 
referred  to,  but  it  must  be  understood  that  such  explanations 
are  superfluous  when  the  attitude  of  the  foetus  before  labour 
is  normal.  The  conventional  explanations  of  the  movement 
of  flexion  are  : 

(a)  The  Wedge  Theory. — When  the  foetal  head  is  looked 

at  from  the  side  it  will  be 
observed  that  this  outline 
forms  a  wedge  with  un- 
equal sides  ;  the  apex  of 
the  wedge  is  near  the  pos- 
terior end  of  the  sagittal 
suture,  and  the  posterior 
side  is  steeper  than  the 
anterior  (Fig.  135).  Li  a 
vertex  presentation,  when 
the  head  is  incompletely 
flexed,  the  steep  posterior 
side  of  the  wedge  will 
meet  with  less  resistance 
from  contact  with  the 
passages  than  the  an- 
terior— i.e.,  the  occi23ut 
will  advance  more  quick- 
ly than  the  sinciput,  and 
the  head  will  thus  tend 
to  move  upon  the  occipito-atloid  articulation  into  the 
attitude  of  flexion.  This  effect  will  be  increased  by  the 
elastic  pressure  exercised  by  the  resisting  girdle  of  contact, 
for  this  pressure  is  applied  to  the  front  and  back  of  the  head 
at  slightly  different  levels,  thus  forming  a  couple  of  forces, 
the  tendency  of  which  must  be  to  rotate  the  head  still  further 
upon  its  transverse  axis  so  as  to  bring  the  occiput  lower  than 
the  sinciput  (Figs.  136  and  137).  These  effects  will  be  pro- 
duced at  all  periods  of  the  first  and  second  stages  whether 
the  membranes  are  ruptured  or  not. 

(b)  Obliquity  of  the  Uterus. — It  has  been  mentioned  that 


Fig.  135. — Effect  of  the  Wedge  Shape 
of  the  Head  in  producing  Flexion. 
(Modified  from  Galabin.) 

A,  B.  Diameter  of  engagement.  C,  D.  Slope  of 
anterior  side  of  lateral  wedge.  B,  D.  Slope  of 
posterior  side  of  lateral  wedge.  The  ariows 
indicate  the  effect  of  the  elastic  pressure  of  the 
gii-dle  of  contact. 


MECHANISM 


295 


the  gravid  uterus  at  term  is  normally  inclined  a  little  to  one 
or  other  side  of  the  middle  line,  usually  to  the  right.  From 
this  it  has  been  argued  that  force  transmitted  in  the  uterine 
axis  will  be  directed  obliquely  to  the  side  opposite  to  that  to 
which  the  uterus  is  inclined.  Therefore,  with  right  uterine 
obliquity,  when  the  occiput  lies  to  the  left,  the-  greater  force 
applied  to  the  posterior  end  of  the  head  will  promote  flexion 
by   causing   the   head    to   move    upon   the   occipito-atloid 


Fig.  13(1. — Vertex  Presentation.  First  Position.  The  head  is  incom- 
pletely flexed,  the  diameter  of  engagement  being  approximately  the 
occipito-frontal ;  pelvis  divided  in  right  oblique  diameter.  (Faraboeuf 
and  Varnier.) 

articulation.  If  the  obliquity  of  the  uterus  should  be  left 
instead  of  right,  then  extension  would  be  promoted  instead  of 
flexion,  the  uterine  force  acting  more  powerfully  upon  the 
sinciput.  It  is  probable,  however,  that  little  importance  can 
be  attached  to  this  mechanism  under  normal  conditions,  for 
when  the  uterus  contracts  it  tends  to  become  erect,  thus 
diminishing  its  lateral  obliquity  ;  the  position  it  occupies 
when  at  rest  can  have  no  effect  upon  the  advance  of  the  head. 
It  must  be  recollected  that  when  flexion  is  deficient  the 
diameter  of  engagement  is  longer  than  when  it  is  complete 


296 


NORMAL   LABOUR 


(Figs.  136  and  137),  and  the  difficulties  attending  the  passage 
of  the  head  are  consequently  greater.  When  the  head  is 
flexed  to  the  greatest  possible  extent,  the  sub-occipito- 
bregmatic  diameter  engages.  The  shape  of  the  head  in  the 
plane  of  this  diameter  is  shown  in  Fig.  138,  a  ;  its  dimensions 
are  well  within  those  of  the  pelvic  brim  or  cavity.  When  the 
head  is  less  fully  flexed  the  sub-occipito-frontal  diameter 
becomes  engaged  ;  the  shape  and  size  of  the  plane  of  this 
diameter  are  shown  in  Fig.  138,  b.     This  plane  is  approxi- 


^ 

Y 

yd  A 

1 

Fig.  137.— Vertex  Presentation.  Fii'st  Position.  The  head  is  completely 
flexed,  the  diameter  of  engagement  being  the  sub-occipito-bregmatic. 
(FaraboDuf  and  Yarnier.) 

mately  quadrilateral,  and  is  therefore  not  so  well  adapted 
to  pass  easily  through  the  pelvis,  while  its  dimensions  are 
of  course  greater  than  those  of  the  sub-occipito-bregmatic 
plane.  AA^en  the  head  is  midway  between  complete  flexion 
and  complete  extension,  the  occipito-frontal  diameter 
engages,  and  the  plane  of  this  diameter  has  the  same  shape, 
but  is  of  even  larger  size  than  the  sub-occipito-frontal 
(Fig.  139).  It  will  therefore  be  apparent  that  complete 
flexion  of  the  head  is  of  great  mechanical  advantage  in  a 
vertex  j)resentation,  since  in  this  position  the  plane  of 
engagement  is  not  only  the  smallest  possible,  but  also  of  a 


MECHANISM 


297 


shape  which  will  readily  pass  through  the  pelvic  canal.  It  is, 
however,  probable  that  at  the  beginning  of  labour  the  head 
usually  engages  in  the  sub-occipito-frontal  plane,  or  in  a 
plane  intermediate  between  this  and  the  sub-occipito- 
bregmatic,  and  if  the  dimensions  of  the  head  and  the  pelvis 


Fig.  138. — a,  The  Position  and  Shape  of  the  Sub-Occipito-Bregmatic  Plane 
of  the  Poetal  Head,  h,  The  Position  and  Shape  of  the  Sub-Occipito- 
Frontal  Plane  of  the  Foetal  Head.     (Edgar.) 


are   normal,    it   may   pass    through    without    any    marked 
increase  of  flexion  being  produced. 

II.  Internal  Rotation. — The  head  enters  the  pelvic  brim, 
as  we  have  seen,  approximately  in  the  oblique  diameter  ;  in- 
ternal rotation  is  a  movement  which  carries  the  head  into  the 
antero-posterior  diameter  of  the  pelvic  outlet.  The  advan- 
tage  gained  by  this   movement   is  that   the   diameter   of 


298 


NORMAL   LABOUR 


OCCIPUT 


engagement  is  brought  into  the  longest  diameter  of  the  pelvic 
outlet,  for  when  the  coccyx  is  extended  the  antero-posterior 
measures  about  5|  inches.  In  the  first  and  second  positions 
internal  rotation  almost  always  brings  the  occiput  forwards 
under  the  pubic  arch  ;  in  the  third  and  fourth  positions  the 
same  thing  usually  occurs  ;  but  sometimes,  from  causes 
which  will  be  mentioned  later,  the  occiput  rotates  backwards 

into  the  sacral  hollow 
while  the  sinciput  comes 
to  the  front.  In  the  first 
and  fourth  positions  the 
direction  of  forward  rota- 
tion is  from  left  to  right ; 
in  the  second  and  third 
from  right  to  left. 

Forward  Rotation  of 
the  Occiput. — The  essen- 
tial cause  of  this  move- 
ment is  the  influence  of 
the  sloping  jjelvic  floor. 
As  we  have  seen,  the  soft 
parts  forming  the  pelvic 
floor  slope  from  behind 
forwards  and  downwards, 
and  from  the  sides,  for- 
wards, downwards,  and 
inwards  —  towards  the 
middle  line.  Therefore  a 
body  coming  in  contact 
with  any  part  of  the  pel- 
vic floor  will  be  directed 
by  it  forwards  and  down- 
wards under  the  pubic  arch.  When  the  head  is  flexed  the 
posterior  part  of  the  vertex  reaches  the  pelvic  floor  in 
advance  of  the  anterior  (Fig.  137),  and  is  accordingly  directed 
forwards  by  its  slope  ;  in  other  words,  the  occiput  rotates 
under  the  pubic  arch.  This  will  occur  whether  the  occiput 
lies  in  an  anterior  or  a  posterior  position.  Since  the  pelvic 
floor  is  deficient  anteriorly  in  relation  to  the  wide  pubic 
arch,  the  part  of  the  head  which  moves  forward  is  moving 
in  the  direction  of  least  resistance,  and  there  is  nothing  to 


Fig.  139.— The  Position  and  Shape  of 
the  Occipito-Frontal  Plane.     (Edgar.) 


MECHANISM 


299 


oppose  it.  The  movement  of  forward  rotation  is  much 
longer  in  the  case  of  posterior  than  anterior  positions  of  the 
vertex,  the  difference  being  represented  by  about  a  quarter 
of  a  circle. 

Braune's  section  of  a  woman  who  died  during  the  second 
stage  (Fig.  100)  shows  the  movement  of  internal  rotation  in 
progress,  the  occiput  coming  forwards,  while  dilatation  of  the 
vulva  has  begun. 

Backward  Rotation  of  the  Occiput.— li,  in  an  occipito- 
posterior  position,  the  head  is  extended  so  as  to  bring  the 
occipito-frontal  diameter  into  the  pelvic  brim,  the  anterior 
end  of  the  vertex  will  form  its  lowest  part.  When  this  part 
reaches  the  pelvic  floor  it  will  be  directed  downwards  and 
forwards  under  the  pubic 
arch,  and  the  occiput  will 
consequently  pass  backwards 
into  the  sacral  hollow.  The 
primary  cause  of  backward 
rotation  is  therefore  exten- 
sion of  the  vertex.  While  it 
is  extremely  rare  in  anterior 
positions,  extension  is  not 
uncommon  in  posterior  posi- 
tions, and  is  amply  accounted 
for  by  two  considerations  : 
(1)  In  posterior  positions  the 
general  attitude  of  flexion  is 
disturbed  by  some  degree  of  extension  of  the  spine  which 
results  from  the  opposition  of  the  two  convexities  of  the  foetal 
back  and  the  maternal  lumbar  vertebrse  ;  if  the  foetal  spine 
becomes  extended  the  foetal  head  will  become  extended  also. 
This  implies  that  some  degree  of  extension  is  present  at  the 
commencement  of  labour.  (2)  Extension  may  be  produced 
or  increased  during  labour  by  the  unfavourable  position  in 
which  the  head  is  placed  (Fig.  140).  The  widest  part  of  the 
foetal  head  lies  behind  its  centre  and  corresponds  to  the 
bi-parietal  diameter.  In  a  posterior  position  this  diameter 
lies  behind  the  oblique  diameter  of  the  brim,  between  the 
sacral  promontory  and  the  ilio-pectineal  eminence — a 
position  where  space  is  limited,  and  it  therefore  meets  with 
opposition  to  its  descent.     The  narrow  sincipital  end,  on  the 


Fig.  140.— OcciiDito-Posterior  Posi- 
tion of  the  Vertex      (Herman.) 

The  dotted  Udc  indicates  the  bi-parietal 
diameter. 


300 


NORMAL   LABOUR 


other  hand,  lies  m  the  mdest  part  of  the  pelvis  where  it  can 
descend  easily  ;  consequent^  the  head  becomes  extended. 
Another  possible  factor  in  the  production  of  backward 
rotation  may  also  be  mentioned .  If  the  vertex  is  so  extended 
as  to  make  the  occipito-f rental  the  diameter  of  engagement, 

the  length  of  the  transverse  diame- 
ter of  the  pelvic  cavity  will  form  a 
mechanical  obstacle  to  forward  rota- 
tion of  the  occiput.  This  diameter 
measures  4|  inches — i.e.,  about  the 
same  as  the  occipito-frontal  ;  yet, 
if  forward  rotation  occurs,  the  head 
must  pass  through  this  diameter 
before  the  occiput  can  reach  the 
pubic  arch.  It  mil  clearly  be  easier 
for  the  occiput  to  pass  backwards, 
thus  bringmg  the  diameter  of  en- 
gagement immediately  into  the  long 
diameter  of  the  outlet.  If  the  ver- 
tex is  flexed,  no  difficulty  will  be 
occasioned  in  forward  rotation  by 
the  length  of  the  transverse  diame- 
ter. In  the  case  of  certain  varie- 
ties of  contracted  pelvis  the  inclined 
planes  of  the  ischium  control  the 
movement  of  internal  rotation,  but 
for  the  reasons  stated  on  p.  413  they 
are  probably  inoperative  in  normal 
labour. 

It  will  be  understood  from  what 
has  been  said  that,  while  backward 
rotation  may  exceptionally  occur  in 
anterior  positions,  this  occurrence  is 
extremely  rare  and  can  only  be  ren- 
dered possible  by  marked  extension 
of  the  head.  Li  posterior  positions  it  occurs  in  about  one 
case  in  ten.  ^Yhen  backward  rotation  takes  place  the  con- 
dition is  called  a  yersistent  occijnto-posterior  or  face-to-pubes 
case. 

III.  Extension. — After  mternal  rotation  has  been  com- 
pleted the  head  emerges  at  the  vulva,  the  occiput  coming 


Fig.  141. — Fcetus  from  a 
Frozen  Section  of  a 
WoDian  who  Died  in 
Labour  towards  the 
End  of  the  Second 
Stage ;  showing  Exten  - 
sion  of  the  Trunk. 
(Barbour. ) 


MECHANISM 


301 


(a)  (5) 

Fig.  142. — The  Stages  of  the  Movement  of  Extension  in  the  Expulsion  of  the 

Head. 


Fig.  143.— The  Stages  of  the  Movement  of  Extension  in  the  Expulsion  of  the  Head. 


302 


NORMAL  LABOUR 


first,  then  successively,  the  vertex,  forehead,  and  face. 
When  the  chm  shdes  over  the  edge  of  the  perineum,  it  of 
course  becomes  separated  from  the  chest-wall — i.e.,  the 
head  becomes  extended.  It  is  probable,  however,  that 
extension  begins  earlier  than  this,  and  is  in  fact  part  of  a 
general  change  in  the  attitude  of  the  foetus  which  takes 
place  towards  the  end  of  the  second  stage.     The  attitude  of 


Fig.  144. — Showing  the  Position  of  the  Shoulders  hefore  the 
Movement  of  External  Eotation. 


the  foetus  shown  in  Fig.  141  is  the  same  as  that  seen  in  utero 
in  Fig.  142.  When  carefully  examined  it  will  be  noticed  that 
flexion  of  the  trunk  is  not  nearly  so  marked  as  before  the 
onset  of  labour,  this  change  being  clearly  indicated  by  the 
interval  which  here  exists  between  the  folded  arms  and  the 
knees.  The  chin  is  also  no  longer  in  contact  with  the  chest. 
In  other  words,  extension  has  already  begun  ;  it  is  probably 
a  normal  occurrence  at  this  stage  of  labour.  Complete 
extension  of  the  head  only  occurs,  however,  in  the  actual 


MECHANISM  303 

process  of  expulsion  through  the  vulva.  The  steps  of  this 
process  are  shown  in  Figs.  142  and  143.  It  will  be  observed 
that  the  interval  between  the  chin  and  the  chest  wall 
progressively  increases  as  the  head  is  expelled,  while  the 
back  of  the  neck  becomes  bent  over  the  pubes. 

IV,  Restitution  and  External  Rotation. — These  are  move- 
ments of  the  neck  and  trunk,  the  head  being  merely  the 


Fig.  145. — Showing  the  Position  of  the  Head  and  Shoulders  after  the 
Movement  of  External  Rotation. 

index.  (1)  Restitution. — While  the  head  is  emerging  in  the 
antero -posterior  diameter  of  the  outlet,  the  shoulders  engage 
in  the  oblique  diameter  of  the  brim  (Pig.  144).  In  this 
attitude  there  is  slight  torsion  of  the  neck,  and  when  the  head 
is  free  a  slight  movement  occurs,  bringing  it  back  into  its 
normal  relation  to  the  bis-acromial  diameter.  In  first  and 
fourth  vertex  positions  this  movement  is  represented  by  a 
slight  turn  of  the  occiput  to  the  mother's  left ;  in  second 
and  third  to  the  mother's  right. 


304 


NORMAL  LABOUR 


(2)  Exterjial  Rotation  represents  the  movement  of  the 
shoulders  from  the  obHque  diameter  of  the  brim  to  the 
antero-jDosterior  diameter  of  the  outlet,  in  which  they  are 
born.  The  anterior  shoulder  rotates  forwards  under  the 
pubic  arch,  and  in  first  vertex  positions  this  movement 
carries  the  occiput  still  further  round  to  the  mother's  left, 
so  that  the  face  is  now  directed  to  the  right  thigh  (Fig.  145). 
External  rotation  is  thus  a  continuation  of  the  movement  of 
restitution. 

It  is  unnecessary  to  describe  separately  the  movements  of 
the  head  in  all  four  positions  of  the  vertex.    Posterior  posi- 


!FiG.  146.- — -Head  Moulding,  showing  Overlapping  of  Bones  at  the  Lamb- 
doidal  and  Sagittal  Sutures.     (Eibemont-Dessaignes  and  Lepage.) 


tions  differ  from  anterior  chiefly  in  their  Habihty  to  be 
associated  with  deficient  flexion  and  in  the  variation  of  the 
movement  of  internal  rotation  which  is  thus  brought  about. 
As  regards  internal  rotation,  the  conditions  which  induce 
forward  or  backward  rotation  have  been  indicated.  In  the 
movements  of  restitution  and  external  rotation,  the  occijjut 
always  moves  to  the  side  where  it  lay  at  the  commencement 
of  labour. 

Effect  of  Labour  upon  the  Foetal  Head. — The  pressure  to 
which  the  head  is  subjected  during  labour  occasions  certain 
alterations  in  the  relations  of  the  movable  bones  of  the  vault 
of  the   skull  to   one   another  ;     these   changes   are  termed 


HEAD   MOULDING 


305 


Fig.  147.- — Slight  Moulding  of  the  Foetal  Head  in  Vertex  Presentation, 
with  small  Caput  about  the  middle  of  the  Eight  Parietal  Bone. 
(Bumm.) 

The  linear  outline  represents  tlie  shape  of  the  head  before  labour. 


Fig.  148. — Extreme  Moulding  of  the  Foetal  Head  in  Vertex  Presentation, 
with  Large  Caput  on  the  posterior  part  of  the  Eight  Parietal  Bone. 
(Bumm.) 

moulding  of  the  head.     The  tabular  portion  of  the  occipital 
bone   becomes   depressed   so   as   to   deepen   the   posterior 
fontanelle,  while  the  edge  of  the  bone  slides  under  the 
E.M.  20 


306 


NORMAL   LABOUR 


posterior  edges  of  the  parietal  bones  (Fig.  146).  The  same 
change  occurs,  but  to  a  less  marked  extent,  at  the  sagittal 
suture  ;  one  or  other  parietal  bone  becomes  slightly  depressed 
beneath  its  fellow  along  the  sagittal  suture.  The  general 
effect  of  these  changes  is  also  seen  in  an  altered  shape  of  the 
foetal  head  ;  the  pressure  of  the  giixUe  of  contact  is  applied  in 
the  plane  of  the  sub-occipito-bregmatic  or  sub-occipito- 
frontal  diameters  ;  this  plane  therefore  becomes  somewhat 
compressed,  while  compensatory  elongation  occurs  in  the 
plane  at  right  angles  to  it — i.e.,  the  occipito-mental  plane. 
The  head  consequently  becomes  lengthened  in  its  occipito- 
mental diameter  (occipital  tuberosity  to  pomt  of  chin)  and 

shortened  m  its  sub-occipito- 
frontal diameter  (Fig.  147).  The 
effect  of  moulding  in  occipito- 
posterior  positions  is  described 
on  p.  342.  The  degree  of 
moulding  met  with  is  propor- 
tional to  the  pressure  to  which 
the  head  is  subjected  during 
labour  ;  in  the  case  of  an  over- 
sized head  or  an  under-sized 
pelvis  extreme  moulding  of  this 
type  may  occur  (Fig.  148). 

The  pressure  of  the  girdle 
of  contact  upon  the  head  also 
indirectlj^  produces  changes 
in  the  scalp.  As  the  head  is 
driven  down,  and  the  passages  dilate,  the  part  of  the  scalp 
lying  in  the  centre  of  the  birth-canal  is  free  from  pressure, 
while  the  part  immediately  above  and  around  it  is  firmly 
compressed  by  contact  with  the  maternal  tissues.  From 
interference  with  venous  return  effusion  of  serous  fluid  mto 
the  subcutaneous  cellular  tissue  takes  place  upon  the  exposed 
area  of  the  scalp,  forming  a  swelling  known  as  the  caput 
succedaneum.  It  is  clear  that  this  change  will  occur  at  the 
end  of  the  first  and  during  the  second  stages  of  labour  ; 
it  is  seldom  met  with  until  after  the  membranes  have  rup- 
tured. In  the  first  position  of  the  vertex  the  right  parietal 
bone  lies  in  front  of  and  below  the  left,  and,  owing  to  the 
flexed  position  of  the  head,  the  posterior  end  of  the  bone 


Fig.  149. — Caput  Succedaneum 
iu  First  Vertex  Position. 
(Eibemont-Dessaignes  and 
Lepage.) 


CAPUT   SUCCEDANEUM  307 

lies  at  a  lower  level  than  the  anterior.  The  exposed  area 
therefore  corresponds  to  the  posterior  end  of  the  right  parietal 
bone,  close  to  the  sagittal  suture  (Figs.  131  and  132),  and  in 
this  position  the  caput  forms.  The  size  of  the  caput  is  jjro- 
portional  to  the  degree  of  compression — which  again  depends 
upon  the  relation  in  size  of  the  head  and  the  pelvis — and 
to  the  length  in  time  which  elapses  between  rupture  of  the 
membranes  and  expulsion  of  the  head.  The  presence  of  a 
large  caput  upon  the  head  is  therefore  an  important  sign  of 
difficulty  in  labour.  The  side  of  the  head  upon  which  the 
caput  is  formed  depends  upon  'position  ;  its  exact  place 
upon  the  parietal  bone  depends  upon  the  degree  of  -fiexion  of 
the  head.  In  first  and  fourth  positions  it  is  on  the  right 
parietal  ;  in  second  and  third  positions  upon  the  left  ; 
when  the  head  is  fully  flexed  it  is  placed  far  back,  close  to  or 
overlapping  the  posterior  fontanelle  ;  when  the  head  is 
incompletely  flexed  it  will  be  found  more  anterior,  and  may 
even  be  near  the  anterior  fontanelle.  The  usual  location  of 
the  caput  is  therefore  as  follows  : 

1st  ijosition  .  .  Posterior  end  of  right  parietal 

2nd       ,,  .  .  Posterior  end  of  left  parietal 

3rd        ,,  .  .  Middle  or  front  of  left  parietal 

4tli        ,,  .  .  Middle  or  front  of  right  parietal 

But  if  in  third  and  fourth  positions  the  head  is  well  flexed, 
the  caput  will  be  formed  nearer  the  posterior  part  of  the 
bone. 

If  after  internal  rotation  has  occurred  the  head  is  lonof 
delayed  on  the  pelvic  floor,  a  caput  will  form  upon  the  part 
of  the  scalp  which  presents  at  the  vulva — i.e.,  the  region  of 
the  occipital  bone  near  the  posterior  fontanelle.  This  is 
sometimes  called  the  secondary  caput  succedaneum  ;  its 
place  is  the  same  in  all  positions  of  the  vertex  when  forward 
rotation  of  the  occiput  has  occurred  ;  it  will  be  found  upon 
the  sinciput  in  face-to-pubes  cases. 

It  will  be  seen  that  the  position  of  the  caput  and  the 
nature  of  the  moulding  are  useful  indications  of  the  position 
occupied  by  the  head  in  the  pelvic  cavity.  They  must  be 
noted  immediately  after  birth,  as  moulding  often  disappears 
in  a  few  hours,  and  the  caput  is  always  absorbed  in  from 
twenty-four  to  forty-eight  hours. 

20—2 


308  NORMAL   LABOUR 

The  Management  of  Normal  Labour 

In  this  section  will  be  considered  (I.)  antiseptics  ;  (II.) 
diagnosis  ;    (III.)  management. 

I.  Antiseptics. — Every  case  of  labour  must  be  conducted 
with  the  most  scrupulous  attention  to  surgical  cleanliness  on 
the  part  of  all  who  are  in  attendance  upon  the  patient. 
Puerperal  infection  is  due  in  the  overwhelming  majority  of 
instances  to  the  introduction  of  pathogenic  organisms  into 
wounds  of  the  genital  canal ;  there  may  be  a  few  exceptions 
to  this  rule,  but  they  do  not  impair  its  general  force.  Under 
ordinary  circumstances  surgical  cleanliness  in  obstetric  work 
cannot  be  attamed  without  the  free  use  of  antiseptics  ;  it  is 
probable  that  '  aseptic  '  midwifery  will  always  be  restricted 
to  lying-in  institutions.  The  great  majority  of  women  will  no 
doubt  at  aU  times  prefer  to  give  birth  to  their  children  in 
their  own  homes,  where  circumstances  are  usually  unfavour- 
able to  the  organisation  of  the  innumerable  details  of  aseptic 
work. 

Preparations. — The  greatest  care  must  of  course  be  taken 
in  preparing  instruments,  catheters,  douche  tubes,  etc.,  before 
use.  These  and  other  obstetric  instruments  such  as  forceps 
can  conveniently  be  boiled  immediately  before  use  in  the 
patient's  room  in  the  obstetric  steriliser  shown  in  Fig.  150. 
This  appliance  is  made  of  suitable  length  to  take  the  usual 
obstetric  instruments,  and  can  be  carried  in  a  bag  of  ordinary 
size.  Before  use  they  must  then  be  taken  carefully  from 
the  steriliser  and  iinmersed  in  a  solution  of  carboUc  acid 
1  in  40,  out  of  which  they  should  be  taken  only  for 
immediate  application.  Catheters  and  douche  nozzles 
should  always  be  boiled  immediately  before  use. 

The  vulva  always  requires  disinfection  ;  in  the  case  of 
cleanly  persons  this  is  comparatively  easy  ;  in  women  whose 
habits  and  surroundings  are  uncleanly  it  may  be  very 
difficult,  so  that  the  vulva  becomes  a  definite  source  of 
possible  infection.  It  would,  without  doubt,  be  an  advan- 
tage in  aU  cases  to  shave  and  disinfect  the  vulva  as  for  a 
surgical  operation,  but  this  would  be  misunderstood  and 
resented  in  private  practice.  .The  vulva  should,  however, 
be  shaved  under  anaesthesia  before  performing  any  of  the 
obstetric    operations  =     Whether  shaved  or  not   the   vulva 


MANAGEMENT 


309 


should  be  well  cleansed  with  soap  and  water,  then  with 
fresh  water,  and  finally  thoroughly  swabbed  with  an  anti- 
septic solution  ;  for  this  purpose  carbolic  acid  (1  in  40)  or 
one  of  the  coal-tar  products  such  as  lysol  or  izal  (1  in  160 — 
i.e.,  a  teaspoonful  to  a  pint)  is  preferable  to  mercurial 
solutions,  for  frequent  swabbing  is  required  during  labour, 
and  the  mercurial  solutions  when  freely  used  cause  a  good 
deal  of  irritation  of  the  mucous  surfaces.  Only  perfectly 
clean  and  fresh  linen,  or  clean  pads  of  absorbent  wool, 
should  be  allowed,  after  the  external  genitals  have  been 
disinfected,  to  come  in  contact  with  them.  Sets  of  sterilised 
swabs  and  towels,  prepared  for  use  during  labour,  can  be 
obtained  from  surgical  instrument  makers.     The  hands  and 


Fig.  150. — Obstetric  SteriHser. 

forearms  of  the  medical  attendant  and  the  nurse  should  first 
be  scrubbed  for  five  minutes  in  hot  water  and  soap  with  a 
boiled  nail-brush  ;  then  the  soap  rinsed  off  in  fresh  hot  water, 
and  the  hands  finally  immersed  for  two  to  three  minutes  in  a 
solution  of  1  in  1,000  biniodide  or  perchloride  of  mercury. 
It  is  almost  superfluous  to  point  out  that  it  is  impossible  to 
sterilise  the  hands  without  first  removing  the  coat,  turning 
the  shirt-sleeves  up  above  the  elbows,  and  removing  rings 
from  the  fingers.  If  the  hands  have  recently  been  infected 
from  contact  with  a  septic  midwifery  case  or  a  suppurating 
wound,  especial  care  must  be  taken,  for  it  is  well  known  that 
skin  actually  infected  with  pathogenic  organisms  is  extremely 
difficult  to  sterilise,  and  the  usual  process  should  be  repeated 
two   or   three   times.     Under   these   circumstances   rubber 


310  NORMAL  LABOUR 

gloves,  previously  boiled  for  ten  minutes,  should  also  in  all 
cases  be  used.  If  the  precautions  mentioned  above  are 
taken,  the  routine  use  of  rubber  gloves  in  conducting  labour 
is  unnecessary,  and  their  cost  forms  an  obstacle  to  their 
general  adoption  in  all  classes  of  midwifery  practice.  But 
in  the  cases  of  patients  suffering  from  infectious  discharges, 
whether  of  specific  or  septic  origin,  sterilised  gloves  should 
always  be  worn  not  alone  in  the  patient's  interest,  but  also 
to  protect  the  hands  of  the  attendant  from  infection,  and 
thus  render  it  practicable  for  him  to  attend  other  cases  with 
safety. 

It  will  be  observed  that  this  technique  falls  short  in  some 
respects  of  that  considered  necessary  for  surgical  operations. 
Strict  surgical  technique  would  require  complete  shaving  and 
disinfection  of  the  vulva  before  delivery,  the  use  of  sterilised 
rubber  gloves  by  the  medical  and  nursing  attendants, 
and  the  provision  of  a  large  and  costly  supply  of  sterilised 
dressings,  towels,  coverings,  etc.  This  again  would  involve 
the  provision  of  hospital  accommodation  for  all  confinements 
among  the  poorer  classes  of  society.  For  a  normal  confine- 
ment such  elaborate  technique  is  unnecessary,  because 
internal  manipulation  can  be  reduced  to  a  minimum  ;  but 
when  interference  requiring  internal  manipulation  is  required, 
the  fullest  surgical  technique  is  a  necessity. 

It  must  be  remembered  that  clothing  also  becomes 
infected  by  contact  with  septic  discharges,  and  possibly  also 
by  exposure  to  the  atmosphere  of  an  ill-ventilated  room  in 
which  a  septic  case  is  lying.  Therefore,  in  the  case  of  an 
obstetric  nurse  who  has  attended  a  septic  case,  the  disinfec- 
tion of  her  clothing  becomes  a  matter  of  the  greatest  impor- 
tance, and  it  is  the  duty  of  the  medical  man  under  whom  she 
works  to  see  that  these  precautions  are  carried  out.  All 
washable  articles  should  be  boiled  ;  the  others  should  be 
sent  to  the  local  sanitary  authority,  by  whom  they  will  be 
efficiently  disinfected  by  heat.  What  is  requisite  for  the 
nurse  is  also  requisite  for  the  medical  attendant,  although 
the  danger  in  his  case  is  less  because  he  is  not  exposed  to  the 
risk  of  contact  with  septic  material  for  such  a  long  period 
as  the  nurse.  A  complete  change  of  clothing  is,  however, 
absolutely  necessary  before  passing  from  a  case  of  infectious 
fever,  of  puerperal  or  surgical  infection,  or  of  suppuration 


MANAGEMENT  311 

of  any  kind,  to  one  of  normal  labour.  When  a  septic 
case  has  been  examined  without  gloves  being  used,  repeated 
disinfection  of  the  hands  must  be  carried  out,  and  gloves 
used  for  all  purposes ;  it  is  well  recognised  that  skin  which 
has  been  exposed  to  contamination  by  virulent  bacteria  is 
exceptionally  difficult  to  sterilise.  If  these  precautions  are 
taken,  it  is  not  necessary  for  the  medical  attendant  or  the 
nurse  to  be  suspended  from  obstetric  work  for  a  longer 
period  than  is  required  for  the  due  performance  of  the 
various  steps  in  disinfection  ;  mere  abstinence  from  work 
and  lapse  of  time  (although  the  latter  may  diminish  the 
virulence  of  organisms  deposited  upon  skin  or  clothing)  are 
not  disinfecting  agents  ;  they  cannot  be  relied  upon  alone, 
and  if  other  methods  are  efficiently  practised  they  are 
unnecessary. 

Of  the  many  antiseptic  substances  employed  in  surgery, 
there  is  a  general  consensus  of  opinion  that  the  mercurial 
salts  are  the  most  reliable  for  the  disinfection  of  the  skin. 
Biniodide  is  preferable  to  perchloride  of  mercury,  because  it 
is  a  slightl}^  more  powerful  germicide,  does  not  roughen  the 
skin  when  frequently  used,  and  does  not  coagulate  albumen, 
nor  corrode  steel  instruments.  The  bactericidal  action  of  a 
solution  of  biniodide  of  mercury  is  increased  by  an  admixture 
of  alcohol  in  the  proportion  of  three  parts  of  solution  to  one 
of  methylated  spirit.  Rubber,  glass,  or  metal  instruments 
should  all  be  sterilised  by  boiling. 

The  question  of  vaginal  douching  will  be  most  con- 
veniently considered  when  dealing  with  the  puerperium 
(p.  544),  but  it  may  be  stated  here  that  douching  is  un- 
necessary before  or  during  labour  in  a  normal  case  when  the 
vaginal  canal  is  healthy.  When  the  membranes  rupture, 
and  again  when  the  body  of  the  child  escapes,  the  passages 
are  flushed  from  above  with  a  large  quantity  of  sterile  fluid 
(the  liquor  amnii),  which  serves  all  the  mechanical  purposes 
of  a  douche  and  has  none  of  its  attendant  risks.  Sometimes 
the  amniotic  sac  becomes  infected  during  labour,  usually 
after,  but  sometimes  before,  rupture  of  the  membranes,  and 
then  of  course  this  advantage  is  lost,  and  if  the  condition  is 
recognised  douching  should  be  employed.  The  best  solution 
to  use  during  labour  is  peroxide  of  hydrogen,  in  the  strength 
of  5  volumes  ;  this  is  a  non-toxic  and  non-irritating  solution. 


312 


NORMAL  LABOUR 


The  presence  of  a  purulent  or  muco-purulent  vaginal  dis- 
charge also  indicates  the  necessity  for  careful  douching  before 
labour  ;  the  best  antiseptics  under  such  circumstances  are 
lysol  1  in  160  or  biniodide  of  mercury  1  in  4,000. 

II.  Diagnosis. — The  first  examination  of  a  woman  in 
labour  should  be  directed  to  the  recognition  of  the  three 
following  points,  which  are  of  great  practical  importance  : 
(1)  the  presentation  and  position  ;  (2)  the  relation  between 
the  size  of  the  foetal  head  and  that  of  the  pelvis  ;  (3)  the 
presence  of  the  foetal  heart-sounds.     These  matters  must  be 


Fig.  151. — The  Abdomen  of  a  Prea-nant  Woman  at  Term. 


settled  at  the  beginning  of  labour,  and  accordingly  the  exami- 
nation should  be  made  as  early  in  labour  as  possible,  unless 
the  medical  attendant  has  taken  the  precaution,  advised  on 
p.  105,  of  making  the  diagnosis  of  these  points  during  the 
latter  part  of  pregnancy.  Only  by  this  method  can  causes 
of  obstruction  be  recognised  in  time  to  avoid  the  serious 
maternal  and  foetal  dangers  to  which  they  give  rise,  when 
their  presence  is  not  detected  until  labour  is  advanced.  Both 
abdominal  and  vaginal  examination  will  be  required.  The 
signs  which  indicate  that  labour  is  actually  in  progress  have 
been  already  described  (p.  243). 

Abdominal  Palpation. — Nearly  all  the  information  re- 


ABDOMINAL   PALPATION 


313 


quired  at  this  stage  can  be  obtained  by  examination  of  the 
abdomen  ;  no  risk  or  discomfort  to  the  patient  is  involved  in 
it,  and  it  may  accordingly  be  freely  employed.  A  certain 
amount  of  skill,  which  can  only  be  attained  by  practice,  is 
required,  and  the  details  of  palpation  are  much  more  readily 
learned  during  pregnancy,  when  the  uterus  is  quiet,  than 
during  labour,  when  it  is  actively  contracting  ;   the  student 


Fig.  152. — Abdominal  Palpation.     Step  I.     Palpating  the  Head  by 
t\iQ  first  pelvic  grip. 

should   therefore   miss   no   opportunity   of   practising   this 
method  during  the  latter  weeks  of  pregnancy. 

The  patient  should  lie  upon  her  back  with  the  shoulders 
slightly  raised,  the  knees  slightly  bent,  and  the  abdomen 
completely  uncovered.  The  hands  should  be  warm,  and 
should  be  used  with  gentleness  ;  if  labour  is  actually  in 
progress,  the  manipulations  should  be  suspended  during  the 
pains.  The  level  of  the  fundus  should  first  be  noted  ;  it 
will  usually  be  found  about  a  hand's  breadth  below  the  tip 


314  NORMAL   LABOUR 

of  the  ensiform  cartilage.  The  parts  of  the  body  of  the  foetus 
which  can  be  recognised  by  palpation  are  the  head,  the  breech, 
the  back,  the  anterior  shoulder,  and  the  folded  limbs  lying 
upon  the  ventral  aspect.  In  normal  labour  the  head  lies  in 
the  lower  uterine  segment  and  the  breech  at  the  fundus,  and 
this  is  the  only  arrangement  with  which  we  are  here  con- 
cerned. The  lower  pole  of  the  foetus  should  first  be  palpated 
by  placing  the  hands  flat  upon  the  lower  part  of  the  abdomen, 
in  the  position  shown  in  Fig.  152  ;  the  finger-tips  are  then 
directed  downwards  and  inwards  and  steady  pressure  is 
made  so  as  to  force  them  towards  the  pelvic  brim,  and  at  the 
same  time  aj)]3roximate  them  to  one  another.  This  is  called 
the  first  pelvic  grip,  and  by  it,  in  a  vertex  presentation,  the 
head  of  the  foetus  may  be  grasped  between  the  two  hands 
and  its  distinctive  characters  made  out. 

It  is  not  in  all  cases  equally  easy  to  feel  the  head  distinctly. 
Thus  in  a  primipara  the  head  may  have  descended  into  the 
jDclvic  brim,  so  that  very  little  of  its  surface  is  accessible  to 
the  touch  of  the  finger-tips.  In  a  multipara  the  level  of  the 
head  early  in  labour  is  higher,  and  a  better  imjDression  of  its 
shape  and  outlines  can  be  obtained.  In  aU  cases  it  can  be 
recognised  that  the  head  forms  a  mass  of  densely  hard  con- 
sistence, and  when  it  hes  low  in  the  brim  there  is  very  little 
mobility.  When  the  head  lies  higher  it  can  be  readily  moved 
from  side  to  side,  and  the  details  of  its  shape  more  easily 
made  out.  Usually  the  patient  experiences  distinct  j)ain  on 
pressure  over  the  head,  but  not  over  any  other  part  of  the 
foetus. 

When  the  head  is  fairly  high  its  oval  shape  can  be  recog- 
nised, and  also  the  direction  in  which  the  long  diameter  lies  ; 
usually  also  the  sincipital  and  the  occipital  ends  of  the  ovoid 
can  be  discriminated.  Before  labour  has  set  in  the  long 
diameter  of  the  head  is  not  infrequently  found  to  occup}'' 
the  transverse  diameter  of  the  pelvic  brim  ;  when  labour  is 
actually  in  progress  it  will  be  found  usually  in  one  of  the 
oblique  diameters.  The  sincipital  end  of  the  long  diameter 
is  broader,  more  prominent,  and  more  irregular  in  outline 
than  the  occiijital  end  ;  but  it  is  only  in  cases  in  which  the 
conditions  are  favourable  for  palj)ation  that  these  points  can 
be  made  out.  The  head  can  be  distinguished  from  the 
breech  at  the  pelvic  brim  by  the  following  points  : — It  is 


ABDOMINAL   PALPATION 


315 


harder  than  the  breech,  better  defined  in  outline,  and  is 
separated  from  the  trunk  by  a  groove  corresponding  to  the 
neck  ;  by  firmly  drawing  the  fingers  upwards  from  the  head 
to  the  trunk  the  presence  of  this  groove  can  usually  be 
determined.  In  a  multij^ara  the  head  usually  lies  above  the 
level  of  the  plane  of  the  brim  at  this  stage  of  labour,  and 
therefore  it  can  be  more  easily  grasped.  The  head  may  then 
be  better  felt  by  the  second  pelvic  grip,  in  which  the  ulnar 
margin  of  the  hand  is  placed  upon  the  pubes,  and  the  thumb 
and  fingers  spread  so  as  to  include  the  head  between  them 


Fig.  153. — Abdominal  Palpation.     Step  I.     Palpating  the  Head  by  the 
second  pelvic  grip. 

(Fig.  153).  It  will  be  evident  that  the  second  pelvic  grip 
will  be  more  useful  when  the  head  is  high,  the  first  pelvic 
grip  when  the  head  is  low.  In  the  former  case  the  head  can 
be  readily  moved  from  side  to  side  ;  in  the  latter  case,  as  it 
lies  in  the  pelvic  brim,  it  is  almost  immovable. 

The  fundus  of  the  uterus  is  next  palpated  with  the  two 
hands  laid  flat  upon  it  {fundal  grip),  the  observer  reversing 
his  position  so  as  to  stand  facing  the  patient  (Fig.  154)  ;  the 
breech  in  this  position  will  be  felt  to  be  larger,  softer,  and 
more  irregular  in  outline  than  the  head  ;  one  buttock  can 
often  be  felt  as  a  firm,  distinctly  rounded  prominence.     The 


316 


NORMAL  LABOUR 


buttock  is,  however,  much  smaller  than  the  head,  and  can 
often  be  felt  to  rotate  beneath  the  fingers  as  the  trunk  of  the 
foetus  moves  spontaneously  round  its  vertical  axis.  Small 
rounded  prominences  representing  the  feet  are  usually  to  be 
felt  in  the  same  region  as  that  in  which  the  buttocks  lie  ; 
there  are,  however,  certain  exceptions  to  this  statement 
(p.  361).     These  small  parts  can  be  readily  displaced  by  the 


Fig.  154. — ALdomiual   Palpatiou,      Step  II. 

the  funded,  yrip. 


Palpating  tlie  Breech  br 


observer,  and  can  often  be  felt  to  make  vigorous  spontaneous 
movements. 

The  front  and  sides  of  the  uterus  are  next  to  be  palpated 
{lateral  grip)  in  order  to  locate  the  back  and  the  limbs  (Fig. 
155).  It  will  be  remembered  that  the  head  engages  in  one 
or  other  oblique  diameter  of  the  brim  ;  in  the  first  and  second 
positions  a  large  area  of  the  back  is  accessible  to  palpation  ; 
in  the  third  and  fourth  positions,  however,  only  a  small  part 
of  the  back  is  accessible,  while  the  limbs  will  be  readily  felt 
(Fig.  128).     These  differences  in  the  disposition  of  the  foetal 


ABDOMINAL   PALPATION 


317 


parts  lead  to  a  certain  difference  in  the  shape  and  outline  of 
the  uterus  which  can  be  observed  on  inspection  in  a  favour- 
able case.  Thus  in  anterior  positions  the  anterior  abdominal 
wall  forms  a  boldly  marked  convexity  of  uniform  outline, 
while  in  posterior  positions  it  is  distinctly  flatter,  and  in  thin 
subjects  it  is  irregular  in  outline  over  the  position  of  the 


Fig.  155. — Abdominal   Palpation.     Step   III.     Palpating  the  Back  and 
Limbs  by  the  lateral  grip. 


folded  limbs.  Irregularities  of  outline  corresponding  to  the 
limbs  can  often  be  observed  at  one  or  other  side  of  the 
uterus  in  an  anterior  position.  On  palpation  the  back 
forms  an  extensive,  smooth,  rounded  area,  over  which  the 
fingers  pass  without  interruption.  The  limbs,  on  the  other 
hand,  are  felt  as  irregularities,  or  as  definite  knobs,  which 
can  be  displaced  by  the  fingers,  and  which  can  also  often  be 
felt  to  make  spontaneous  movements.     In  anterior  positions 


318  NOR]\IAL   LABOUR 

the  back  appears  to  occupy  the  greater  part  of  the  uterus, 
while  the  limbs  are  only  to  be  felt  M'ell  to  one  or  other  side 
of  the  micl-line.  In  posterior  positions  the  back  may  not 
be  definite^  recognised  at  all,  while  the  limbs  are  recognisable 
on  hotli  sides  of  the  mid-line. 

The  position  of  the  anterior  shoulder  should  also  be 
sought.  It  forms  a  well-marked  prominence  in  the  lower 
part  of  the  uterus  a  httle  above  the  head  (Fig.  126)  and 
will  be  found  to  the  right  of  the  middle  line  in  second  and 
third  positions,  to  the  left  in  first  and  fourth  positions  : 
it  is  nearer  the  middle  Ime  in  anterior  than  in  posterior 
positions. 

It  will  now  be  apparent  that  it  is  possible  to  make  a  com- 
plete diagnosis  of  presentation  and  position  from  abdommal 
palpation  alone.  Thus  the  head  is  in  the  pelvic  brim — vertex 
pi'esentation  :  the  back  is  readily  felt — anterior  {first  or 
second)  j^osition  ;  in  addition,  the  limbs  are  to  the  right  of 
the  middle  line — first  jjosition  ;  or  the  back  cannot  be  located, 
but  the  limbs  are  readily  felt — posterior  {third  or  fourth) 
position.  It  must,  however,  be  recollected  that  the  four 
'  positions  "  of  the  vertex  recognised  in  the  British  system 
of  midwifery  are  not  the  only  positions  in  which  the  head  may 
lie.  It  may  take  up  an  intermediate  position  between  the 
first  and  fourth,  or  between  the  second  and  third,  and  also, 
though  more  rarely,  between  the  first  and  second.  Cases  will, 
therefore,  occur  in  which  the  exact  '  position  '  of  the  head 
cannot  be  defined  as  belongmg  to  either  of  the  four  recognised 
'  positions.' 

Auscidtation  of  the  foetal  heart  also  yields  valuable  uif or- 
mation  in  diagnosis  ;  not  only  does  it  mdicate  presentation 
and  position  by  the  locaHty  over  which  it  is  audible,  but  when 
heard  it  also  proves  that  the  foetus  is  hving,  while  by  the 
changes  which  it  undergoes  during  labour  timely  warnuig  of 
danger  to  the  fcetus  may  be  given. 

The  foetal  heart-somids  can  best  be  heard  hj  usmg  a 
smgle  wooden  stethoscope  and  pressing  it  firmh''  against  the 
abdommal  wall  over  the  back  of  the  foetus  (Fig.  156).  The 
part  of  the  foetal  back  over  which  the  heart-sounds  are  best 
heard  is  the  scapular  region.  The  position  occupied  by  this 
area  in  relation  to  the  mother's  abdominal  waU  varies  with 
both  presentation  and  position  (see  Figs.  126  to  129),  and 


AUSCULTATION 


319 


the  stethoscope  must  be  moved  from  place  to  place  until  the 
point  of  maximum  intensity  of  the  sounds  has  been  located. 
Often  they  can  be  heard  over  a  wide  area  of  the  abdomen, 
and  it  is  then  important  to  fix  the  point  at  which  they  are 
loudest.  In  the  first  position  of  the  vertex  the  heart-sounds 
are  heard  best  at  a  point  about  midway  between  the  umbili- 
cus and  the  left  anterior  superior  iliac  spine  (Fig.  157).  This 
point  corresponds  almost  exactly  to  the  position  of  the  left 
scapula,  i.e.,  the  point  on  the  foetal  body  at  which  the  heart- 


FiG.  156. — Showing  the  usual  Position  of  the  Point  of  Maximum 
Intensity  of  the  Fcetal  Heart-soimds  in  a  Case  of  Second  Position 
of  the  Vertex. 


sounds  will  be  most  clearly  heard.  In  the  second  position 
the  point  of  maximum  intensity  is  less  definite.  Often  it  is 
in  the  middle  line,  half-way  between  pubes  and  umbilicus  ; 
almost  as  often  it  is  somewhere  about  the  centre  of  a  line 
drawn  from  the  umbilicus  to  the  right  anterior  superior 
spine.  In  the  second  position  the  left  scapula  is  not  in  con- 
tact with  the  abdominal  wall,  and  the  point  upon  the  back  of 
the  foetus  where  the  heart  sounds  are  most  clearly  heard  is 
variable.  In  the  third  position  they  are  usually  best  heard 
at   a   slightly  higher  level,   but  further  from  the  middle 


820 


NORMAL   LABOUR 


line  towards  the  flank  ;  occasionally,  however,  they  will  be 
best  heard  in  the  mid-line,  rather  nearer  the  umbilicus  than 
the  pubes.  When  heard  in  the  latter  position  there  is  pro- 
bably sufficient  extension  of  the  trunk  to  throw  the  chest 
forwards  agamst  the  anterior  uterine  wall.  Li  the  fourth 
position  it  is  more  difficult  to  find  the  heart-sounds  than  in 


Fig.  157. — The  Points  of  Maximum  Intensity  of  the  Foetal 
Heart-sounds  in  Vertex  and  Breech  Presentations. 

V  =  vertex  presentation.    B  =  breech  presentation. 

any  other.  ^Yhen  heard  they  are  usually  found  well  out- 
wards towards  the  left  flanli.  When  palpation  fails  to  settle 
the  diagnosis  of  position,  it  is  clear  that  valuable  aid  can  be 
obtained  by  locaHsing  the  point  of  maximum  intensity  of 
the  foetal  heart-somids. 

The  rate  of  the  foetal  heart-sounds  at  term  varies  from 
120  to  140  per  minute  ;  sex  has  no  definite  influence  upon 
the  rate,  nor  lias  size,  although  some  observers  beheve  that 


VAGINAL   EXAMINATION 


321 


a  large  child  has  usually  a  slower  heart-beat  than  a  small 
one.  The  foetal  heart-rate  is  slowed  during  the  uterine 
contractions,  but  quickly  recovers  when  they  pass  off.  Pro- 
gressive slowing  of  the  rate  during  prolonged  labour  indicates 
that  the  foetus  is  suffering  from  the  effects  of  pressure,  and 
forms  an  indication  for  rapid  termination  of  labour.  Undue 
rapidity  is  also  an  unfavourable  sign.     If  the  rate  falls  below 


Fig.  158. — Method  of  making  a  Vaginal  Examination  during  Labour. 
The  Labia  are  held  apart  by  Two  Fingers  of  the  Left  Hand  while 
the  Eight  Index  Finger  is  passed  into  the  Vagina. 


100  or  rises  above  160,  danger  to  the  child  is  certain.  It  is 
accordingly  of  importance  to  count  as  well  as  to  locate  the 
foetal  heart-sounds. 

Vaginal  Examination. — This  method  must  be  employed 
as  little  as  possible  during  labour,  owing  to  the  attendant 
risks  of  infection.  Nearly  all  the  information  required  can 
be  obtained,  as  we  have  seen,  by  abdominal  examination 
alone,  and  in  normal  labour  vaginal  examination  for  diagnosis 
is  often  unnecessary.  It  may,  however,  be  required  to 
E.M.  21 


322 


NORMAL   LABOUR 


determine  the  onset  of  labour,  or  to  watch  the  process  of 
dilatation  of  the  cervix. 

In  making  a  vaginal  examination  of  a  parturient  or 
lying-in  woman,  the  medical  attendant  should  first  disinfect 
his  own  hands  and  then  the  vulva  of  the  patient,  if  no  nurse 
is  present  to  do  this.  The  hands  are  then  again  immersed  in 
the  antiseptic  solution,  and,  while  the  fingers  of  the  left  hand 
separate  the  labia,  the  index  finger  of  the  right  hand  is  care- 
fully passed  into  the  vagina,  avoiding  all  contact  with  the 
vulval  hair,  the  patient's  clothing,  or  bed-clothes  (Fig.  158). 
Li  making  the  examination  the  hands  should  be  used  dripping 


Fig.  159.- — The  Left  Lateral  Position.     Patient  prepared  for 
Vaginal  Examination. 

wet  with  the  antiseptic  solution  ;  no  unguent  is  necessary, 
for  the  wet  fingers  will  not  cause  the  patient  the  least  dis- 
comfort, and  it  is  well  known  that  the  so-called  antiseptic 
unguents  possess  no  bactericidal  properties,  and  may  even  be 
a  source  of  danger,  for  in  some  of  them  bacteria  in  a  Kving 
state  may  exist  for  a  long  time.  When  it  is  necessary  to 
repeat  the  examination  the  hands  must  again  be  disinfected, 
and  the  vulva  swabbed  with  the  antiseptic  solution. 

For  a  vaginal  examination  during  labour  the  British 
practice  is  to  place  the  patient  upon  her  left  side,  and  in  this 
position  women  are  usually  dehvered  (Fig.  159).  Modifica- 
tions of  this  posture  are  required  under  special  circumstances 
which  will  be  afterwards  indicated.     In  making  the  first 


VAGINAL  EXAMINATION  323 

vaginal  examination  certain  definite  objects  must  be  kept  in 
view,  and  systematically  dealt  with  one  after  the  other  ; 
unless  this  is  done  no  information  of  value  may  be  obtained, 
or  the  student  may  find  it  necessary  to  repeat  the  examina- 
tion in  order  to  determine  something  he  has  forgotten,  and 
this  needlessly  increases  the  risks.  The  points  should  be 
observed  in  the  order  stated  :  (1)  the  level  at  which  the 
head  lies  in  the  pelvis  ;  (2)  the  size  of  the  dilating  cervix 
and  the  condition  of  its  walls  ;  (3)  the  presence  or  absence 
of  a  bag  of  waters  ;  (4)  the  position  of  the  posterior 
fontanelle. 

The  level  at  which  the  head  lies  during  the  first  stage  of 
labour  is  different  in  a  primigravida  and  a  multigravida. 
In  the  former,  if  the  conditions  are  normal,  the  head  is  low 
enough  to  be  readily  felt  by  the  finger  in  the  vagina  without 
making  upward  pressure  to  reach  it.  This  signifies  that  the 
head  is  '  engaged  '  in  the  brim,  i.e.,  the  greatest  circumfer- 
ence of  the  head  corresponds  with  the  brim,  while  the  vertex 
is  in  advance  and  therefore  lies  lower.  If  in  a  primi- 
gravida the  head  cannot  be  thus  readily  felt,  suspicion  is 
at  once  aroused  that  some  cause  of  obstruction  is  present. 
The  '  engaged  '  head  has  little  mobility,  but  can  be  pushed 
upwards  to  a  slight  extent  during  the  intervals  between  the 
pains. 

In  a  multipara  the  head  usually  lies  above  the  brim, 
and  not  '  engaged,'  until  the  end  of  the  first  stage.  It  can 
then  be  felt  only  by  making  upward  pressure  with  the 
finger,  and  it  will  be  found  to  be  freely  movable  during  the 
intervals  of  the  pains. 

The  walls  of  the  cervix,  and  the  margins  of  the  external 
OS  should  feel  soft  and  yielding  to  the  touch  ;  during  a  pain 
the  margins  of  the  os  may  become  stretched  tightly  over  the 
head,  but  in  the  intervals  they  are  quite  soft.  In  a  primipara 
the  cervix  may  become  completely  '  taken  up  '  before  the 
OS  is  one- third  or  one-half  dilated  ;  the  os  then  appears  to 
the  examining  finger  as  a  circular  aperture  in  the  tightly 
stretched  cervical  wall.  In  a  multipara  the  cervix  dilates 
more  uniformly. 

The  bag  of  waters  may  escape  notice  altogether  unless 
the  examination  is  continued  during  a  pain  ;  in  the  interval  it 
does  not  bulge,  the  membranes  lying  in  contact  with  the 

21—2 


324 


NORMAL   LABOUR 


head.  If  the  hairy  scalp  can  be  recognised  by  the  finger 
it  is  obvious  that  there  is  no  bag  of  waters. 

The  posterior  fontanelle  will  be  detected  if  the  head  is 
well  flexed,  as  explained  below. 

While  the  cervix  is  undilated  and  the  membranes  are 
unruptured,  the  sutures  and  fontanelles  cannot  be  distinctly 
felt,  and  great  care  must  be  exercised  in  avoiding  accidental 
rupture  of  the  bag  of  waters.  Diagnosis  of  position  by 
vaginal  examination  must  usually  be  postponed  until  the 


EiG.  160. —  a.  First  Vertex  Position,  showing  Eolations  of  Posterior 
Pontanelle  and  Sagittal  Suture.  h.  Second  Vertex  Position. 
(Modified  from  Eibemont-Dessaignes  and  Lepage.) 

Patient  in  usual  obstetric  position. 

second  stage,  when  the  necessary  particulars  can  be  made  out 
without  difficulty.  In  the  first  position  the  posterior  fonta- 
nelle will  be  felt  in  the  left  anterior  quadrant  of  the  pelvis  ; 
the  sagittal  suture  runs  backwards  and  to  the  right  in  the 
line  of  the  right  oblique  diameter,  and  the  anterior  fontanelle 
is  out  of  reach  (Fig.  160  a).  When  internal  rotation  has 
occurred,  the  posterior  fontanelle  will  be  found  in  the 
middle  line  anteriorly.  The  disposition  of  the  sutures  and 
fontanelles  in  the  second  position  is  shown  in  Fig.  160  6.  In 
the  case  of  the  posterior  positions,  the  degree  of  flexion 
present  influences  the  disposition  of  the  sutures  and  fonta- 


MANAGEMENT 


325 


nelles  to  a  considerable  extent  ;  when  the  head  is  flexed, 
the  posterior  fontanelle  can  be  felt  in  one  or  other  posterior 
quadrant  of  the  pelvis,  the  anterior  fontanelle  being  out  of 
reach  (Fig.  161  a).  If,  however,  flexion  is  deficient,  the 
anterior  fontanelle  comes  within  reach  and  can  be  felt  in 
the  anterior  quadrant  of  the  pelvis,  while  the  posterior 
fontanelle  can  barely  be  reached  at  all  (Fig.  161  b).  Some- 
times difficulty  arises  in  the  second  stage  owing  to  the 
formation  of  a  large  caput  succedaneum  which  obscures  the 


Fig.  161. — a.  Third  Vertex  Position,  Head  flexed,  b.  Fourtli  Vertex 
Position,  Head  partly  extended,  showing  Anterior  and  Posterior 
Fontanelles  and  Sagittal  Suture.  (Modified  from  Eibemont- 
Dessaignes  and  Lepage.) 

Patient  in  usual  obstetric  position. 


sutures  and  fontanelles.  The  best  guide  to  position  then 
is  the  ear,  which  can  easily  be  reached  when  the  head  is  low  ; 
the  curve  of  the  helix  is  towards  the  occiput. 

III.  Management  of  the  First  Stage. — There  is  little  for 
the  medical  attendant  to  do  during  this  stage  after  the  diag- 
nosis has  been  satisfactorily  made  ;  a  skilled  nurse  is  quite  as 
well  able  to  attend  to  the  patient's  wants  and  watch  the 
course  of  labour  as  a  qualified  medical  practitioner.  A  single 
vaginal  examination  for  diagnostic  purposes  at  this  period 
should  be  enough  ;  if  repeated,  it  should  be  with  the  definite 


326  NORMAL   LABOUR 

object  of  observing  the  progress  of  dilatation  and  the 
advance  of  the  head.  Any  succeeding  examination  should 
be  conducted  with  strict  and  conscientious  antiseptic 
precautions. 

During  this  stage  the  patient  may  be  allowed  to  walk 
about  or  sit,  or  assume  any  position  in  which  she  is  for  the 
time  easy.  An  enema  should  be  given  as  soon  as  labour  has 
definitely  begun,  to  ensure  the  rectum  being  empty  at  the 
time  of  dehvery  ;  and  evacuation  of  the  bladder  from  time 
to  time  should  be  secured,  either  spontaneously  or  by  the 
use  of  the  catheter  if  necessary.  Nourishment  can  be  given 
freely  if  the  patient  is  not  sick  ;  vomiting  at  this  stage  is 
neither  unusual  nor  of  serious  import.  "\'\Tiile  regularly 
recurrmg  pains  are  present  it  may  be  assumed  that  labour 
is  progressing  normally.  If  the  pains  are  irregular,  or  only 
imperfectly  intermittent,  progress  is  usually  slow,  and  it 
may  then  be  necessary  to  observe  the  condition  of  the  cervix. 
The  first  change  is  that  it  becomes  '  taken  up,'  i.e.  the 
projection  of  the  vagmal  portion  into  the  vaginal  canal 
disappears.  In  a  primigravida  the  dilating  cervix  now 
becomes  tightly  stretched  by  the  advancing  vertex,  and  when 
examining  duruig  a  contraction  the  ring  formed  by  the  os 
externum  will  be  felt  to  be  firm  and  well-defined,  the  bag 
of  waters  bulging  through  it  ;  in  the  intervals  it  becomes 
soft  and  relaxed,  while  the  head  recedes  and  the  bag  of 
waters  becomes  collapsed  and  may  be  difficult  to  recognise. 
The  progress  of  dilatation  is  usually  recorded  by  notmg  the 
size  of  the  os  externum,  as — admitting  one  finger,  size  of 
half  a  crown,  size  of  a  crown  piece,  half  dilated,  three  fourths 
dilated.  WTien  fuUy  dilated  the  anterior  hp  of  the  os  is  still 
palpable  between  the  head  and  the  pubes,  but  the  posterior 
lip  will  have  disappeared,  as  it  has  been  drawn  up  above  the 
advancing  head. 

As  soon  as  the  membranes  rupture,  whether  at  the  end 
of  this  stage  or  prematurely,  a  second  vaginal  examination 
should  be  made.  The  hairy  scalp  can  now  be  distinguished 
by  the  finger  and  the  disposition  of  the  sutures  and  fontanelles 
made  out  with  comparative  ease  and  the  diagnosis  of 
position  thus  confirmed.  The  transition  from  the  first  to 
the  second  stage  is  marked  by  a  change  in  the  condition  of 
the  patient  and  in  the  character  of  the  j)ams,  which  has  been 


MANAGEMENT  327 

already  described.  In  a  norma]  labour  proceeding  without 
undue  delay,  two  vaginal  examinations,  one  at  the  s-tart 
and  one  after  rupture  of  the  membranes,  are  all  that  is 
required. 

Apart  from  the  slightly  blood-stained  '  show  '  at  the 
commencement  of  labour,  there  is  no  haemorrhage  during 
the  first  stage  in  a  normal  case.  No  anaesthetics  or  sedatives 
should  be  given  when  this  stage  is  running  a  normal  course. 

Management  of  the  Second  Stage. — During  this  stage 
the  patient  must  lie  down  ;  the  medical  attendant  cannot 
leave  her  except  for  a  very  short  time,  and  he  should  even  then 
remain  within  easy  call.  The  pains  of  this  stage  are  severe, 
and  the  voluntary  efforts  of  the  accessory  muscles  exhaust- 
ing. The  patient  should,  however,  be  encouraged  to  con- 
tinue as  long  as  possible  without  anaesthesia,  as  voluntary 
bearing- down  efforts  greatly  assist  the  descent  of  the  head. 
Towards  the  end  of  this  stage  chloroform  may  be  given. 
Surgical  anaesthesia  is  not  required  except  at  the  time  of 
actual  delivery,  when  the  head  is  emerging  from  the  vulva  ; 
the  pains  then  become  very  severe,  and  are  accompanied  by 
violent  straining  which  may  do  harm.  Partial  anaesthesia 
may,  however,  be  maintained  during  the  latter  part  of  this 
stage  without  injury  to  the  patient  or  the  foetus  ;  it  is  best 
carried  out  by  the  administration  of  chloroform  by  the  open 
method  upon  a  handkerchief  or  a  flannel  mask.  If  an  in- 
haler is  preferred,  that  of  Junker  is  the  safest  and  most 
convenient.  Chloroform  should  be  given  only  during  the 
pains  ;  in  this  way  sufficient  will  be  taken  to  relieve  the 
patient's  suffering  and  cause  her  to  sleep  during  the  intervals. 
While  no  harm  ever  comes  from  giving  chloroform  to  a 
healthy  woman  for  a  considerable  time  in  this  manner,  it 
should  be  remembered  that  complete  anaesthesia,  when 
prolonged,  may  lead  to  uterine  inertia  and  troublesome  post- 
partum haemorrhage.  The  foetal  heart  should  be  auscultated 
from  time  to  time  when  the  second  stage  is  unduly  pro- 
longed. 

Even  in  cases  where  a  complete  diagnosis  has  been  made 
in  the  first  stage  by  external  examination,  a  vaginal  examina- 
tion should  be  made  early  in  the  second  stage  to  confirm  the 
previous  diagnosis,  and  to  note  any  changes  which  may  have 
occurred.     The  head  has  usually  descended  sufficiently  to 


328  NORMAL   LABOUR 

allow  the  whole  area  of  the  presenting  part  to  be  reached  by 
the  finger.  First  the  hp  of  the  os  externum  should  be  sought; 
the  anterior  portion  alone  will  be  felt,  and  its  condition 
should  be  noted  ;  not  infrequently  it  becomes  swollen  from 
oedema  induced  by  compression  between  the  head  and  the 
pubes  ;  normally  it  is  felt  as  a  soft,  thick  fold  of  tissue.  By 
sweeping  the  finger-tip  round  the  presenting  part  the  os  will 
also  be  felt  at  the  sides  and  behind,  if  it  is  incompletely 
dilated.  Next  the  condition  of  the  scalp  should  be  noted  ; 
a  small  caput  may  be  detected,  the  pitting  of  the  tissues  on 
pressure  being  recognisable  by  touch.  A  large  caput  at  this 
period  of  the  second  stage  is  abnormal  and  indicates  some 
degree  of  obstruction.  Next  the  sutures  should  be  sought 
for  and  special  attention  paid  to  the  points  where  sutures 
can  be  felt  to  meet  ;  these  positions  correspond  to  the  f onta- 
nelles,  and  usually  only  one  is  within  reach.  The  distinction 
between  the  anterior  and  posterior  f  ontanelles  is  by  no  means 
so  easily  made  during  labour  as  upon  the  foetal  skull.  The 
bones  are  compressed,  and  the  size  of  the  fontanelles  con- 
siderably reduced.  Further,  if  the  fontanelle  is  not  readily 
accessible  an  erroneous  impression  may  be  produced  by 
feeling  only  a  portion  of  it  ;  thus  if  the  anterior  fontanelle 
is  difficult  to  reach  so  that  only  one  corner  of  it  is  felt,  three 
sutures  only  may  be  discovered,  and  in  consequence  it 
may  be  mistaken  for  the  posterior.  During  labour  the 
depression  of  the  occipital  bone  beneath  the  parietals  is 
exaggerated  hj  compression  so  as  to  deepen  the  floor  of  the 
posterior  fontaneUe  and  throw  up  the  edges  of  the  parietal 
bones  to  an  unmistakable  degree.  In  the  case  of  the  anterior 
fontanelle  the  bones  are  on  a  more  imiform  level,  and  this 
point  is  therefore  one  of  great  diagnostic  importance.  After 
satisfactorily  recognising  the  fontanelle  an  attempt  should  be 
made  to  define  its  position  in  the  pelvis,  and  for  this  some 
experience  is  required.  When  the  posterior  fontaneUe  is  felt 
it  usually  hes  in  the  anterior  half  of  the  pelvis  at  this  stage 
of  labour,  and  inclined  slightlj'  to  one  or  other  side.  Later 
on  in  labour,  after  internal  rotation  has  occurred,  it  will  be 
found  in  the  middle  line,  behind  or  beneath  the  symphysis. 
The  anterior  fontanelle  is  seldom  felt  except  in  occipito- 
posterior  positions. 

It  is  unnecessary  to  make  vaginal  examinations  to  watch 


MANAGEMENT  >  329 

the  descent  of  the  head,  for  the  appearances  described  on 
p.  252  will  indicate  when  the  head  has  reached  the  vulva. 
The  work  of  the  medical  attendant  may  then  be  said  to 
begin,  his  duty  being  to  control  the  passage  of  the  head 
and  body  of  the  foetus  through  the  vulva,  and  as  far  as 
possible  to  avoid  injury  to  the  pelvic  floor.  In  this  country 
women  are  usually  delivered  lying  upon  the  left  side,  with 
the  thighs  partly  flexed  and  the  knees  held  apart  by  an 
assistant. 

Time  should  be  allowed  for  the  actual  expulsion  of  the 
head,  especially  in  the  case  of  a  primipara,  or  whenever  the 
perineal  body  appears  to  be  unusually  resistant.  If  delivery 
is  taking  place  under  anaesthesia  it  will  usually  be  observed 
that  as  the  degree  of  anaesthesia  deepens  the  pains  become 
weakened  and  delayed.  Sometimes  this  effect  is  so  marked 
with  only  slight  degrees  of  anaesthesia  that  labour  practically 
comes  to  a  standstill  and  the  administration  of  chloroform 
has  to  be  stopped.  During  the  delivery  of  the  head  rapid 
progress  is,  however,  undesirable,  and  the  administration  of 
chloroform  should  be  pushed  so  as  to  produce  surgical 
anaesthesia.  It  is  usual  to  speak  of  the  process  of  assisting 
the  delivery  of  the  head  as  '  supporting  the  perineum.' 
This  expression  is  unfortunate,  for  attention  should  be 
mainly  directed  not  to  the  perineum,  but  to  the  head  ;  no 
amount  of  support  applied  to  the  perineum  will  prevent  a 
threatening  laceration  unless  the  movements  of  the  head  can 
be  properly  directed.  The  object  in  view  is  to  deliver  the 
occiput  first,  and  to  prevent  extension  of  the  head  from 
taking  place  until  the  bi-parietal  diameter  is  free  from  the 
vulva.  This  implies  that  the  natural  tendency  to  extension 
of  the  head  at  this  stage  must  be  resisted  up  to  a  certain  point. 
By  making  pressure  upon  the  stretched  perineum  with  the 
palm  of  the  hand,  and  at  the  same  time  allowing  the  occiput 
to  protrude  beneath  the  symphysis,  the  head  will  be  kept 
from  extending  until  the  wide  posterior  part  (bi-parietal) 
diameter)  has  escaped.  The  head  may  then  be  allowed 
gently  to  extend  at  the  end  of  a  pain,  the  face  and  chin  being 
slowly  levered  over  the  perineum  during  an  interval.  This 
method  has  a  definite  mechanical  advantage.  If  the  head 
does  not  extend  until  the  parietal  eminences  are  free,  ex- 
tension brings  successively  the  sub-occipito-bregmatic,  sub- 


330 


NORMAL  LABOUR 


occipito-frontal,  and  sub-occipito-mental  diameters  (each 
measuring  about  3|  inches)  through  the  antero-posterior 
diameter  of  the  outlet  (Fig.  162).  If,  however,  the  head 
should  extend  before  this,  the  occipito-frontal  (4|  inches)  or 
the  occipito-mental  (5  inches)  diameters  must  pass  through 
the  outlet,  or,  if  not  these,  then  certain  intermediate 
diameters  necessarily  longer  than  the  sub-occipito-bregmatic 
and  sub-occipito-frontal.  It  will  thus  be  seen  that  the 
important  point  is  not  the  support  given  to  the  perineum, 


Pig.  162. — Extension  of  the  Head  (Third  Movement)  in  passing  the 
Pelvic  Outlet ;  Sub-Occipito-Frontal  Diameter  engaged ;  the  Bi- 
parietal  Diameter  is  free.     (Bumm.) 


but  the  attitude  of  the  head  when  escaping  from  the  vulva. 
In  spite  of  all  precations  a  certain  amount  of  laceration 
almost  always  occurs  in  a  primipara,  and  even  when  the 
perineal  body  seems  intact  externally  there  may  be  consider- 
able laceration  of  the  lower  part  of  the  posterior  vaginal 
wall. 

Sometimes  the  expulsion  of  the  head  is  rapidly  effected 
by  a  succession  of  violent  pains,  so  that  no  opportunity 
occurs  for  controlling  the  mechanism.  More  often,  and 
especially  in  the  case  of  a  primipara,  a  gradual  advance  with 
each  pain  occurs,   the  head  retreating  completely  in  the 


MANAGEMENT  331 

intervals.  Thus  the  vulva  and  perineal  body  are  gradually 
stretched.  Finally  the  head  reaches  a  position  in  the  out- 
let from  which  it  shows  little  or  no  tendency  to  retreat 
during  the  interval,  and  it  may  then  be  maintained  in  that 
p"osition  by  making  pressure  over  the  stretched  perineal 
body,  while  with  the  other  hand  the  stretched  vulval  ring 
is  slipped  back  over  the  parietal  eminences.  The  head 
will  then  be  easily  freed  by  pushing  forward  the  anterior 
part  which  is  still  within  the  maternal  canal. 

After  the  expulsion  of  the  head  has  taken  place,  a  pause 
in  the  uterine  contractions  occurs.  The  child's  eyes  should 
now  be  wiped  with  pledgets  of  cotton-wool  soaked  in  boric 
lotion,  and  if  the  cord  encircles  the  neck  it  should  be  pulled 
over  the  occiput  and  freed.  If  the  pause  is  a  long  one,  the 
face  will  become  cyanosed  from  the  pressure  exerted  upon  the 
undelivered  trunk.  As  soon  as  the  uterus  contracts  again, 
the  movement  of  external  rotation  will  be  observed,  and 
when  the  bis-acromial  diameter  has  entered  the  antero- 
posterior of  the  outlet,  delivery  of  the  body  may  be  assisted 
by  drawing  the  head  gently  forwards  round  the  symphysis 
and  making  pressure  with  the  other  hand  upon  the  uterine 
fundus  (Fig.  1 6 3).  In  case  of  difficulty  the  index  finger  may 
be  hooked  into  the  axilla  of  the  posterior  shoulder,  and  trac- 
tion thus  made  upon  the  trunk,  in  the  axis  of  the  pelvic 
outlet.  In  order  to  secure  proper  retraction  of  the  uterus, 
the  hand  must  not  leave  the  fundus  during  the  delivery 
of  the  body  of  the  child,  if  the  body  is  delivered  by 
traction. 

Management  of  the  Third  Stage. — The  labour  has  now 
entered  upon  the  third  stage  ;  the  attention  of  the  medical 
attendant  will  be  given  first  to  the  condition  of  the  uterus, 
and  then  to  the  division  of  the  cord.  This  apparently  trivial 
procedure  should  be  carried  out  with  due  antiseptic  pre- 
cautions, the  ligatures  and  scissors  being  boiled  before  use, 
and  the  hands  properly  disinfected  ;  it  is  of  great  importance 
in  the  prevention  of  umbilical  sepsis  in  the  new-born  child. 
The  cord  should  not  be  divided  until  the  child  has  cried 
loudly,  respiration  is  properly  established,  and  the  pulsation 
has  nearly  ceased.  The  child  is  then  wrapped  up  in  blankets 
and  remioved.  The  perineum  should  next  be  examined  to 
note  the  degree  of  laceration,  if  any,  which  has  occurred,  and 


332 


NORMAL  LABOUR 


in  so  doing  the  viilva  should  be  opened  up  with  clean  fingers, 
so  as  to  bring  the  posterior  vaginal  wall  into  view.     The 


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patient  should  now  lie  upon  her  back,  for  in  that  position 
the  uterus  can  be  controlled  much  more  easily  and  effectually 


MANAGEMENT  333 

than  in  the  side  position.  Nothing  should  be  done  except 
gently  to  massage  the  uterus  until  it  is  perceived  that  the 
placenta  has  been  expelled  from  it. 

At  the  beginning  of  this  stage  the  medical  attendant 
should  on  abdominal  examination  carefully  note  the  height 
of  the  fundus,  the  size,  mobility,  and  outline  of  the  uterus, 
and  the  presence  of  the  usual  slight  supra-pubic  hollow. 
All  these  points  can  be  observed  much  more  easily  in  the 
dorsal  than  in  the  side  position.  By  the  changes  which 
occur  subsequently  he  will  be  able  to  recognise  the  detach- 
ment of  the  placenta.  When  separated  from  the  uterine 
wall  the  placenta  falls  into  the  cervix  or  the  vagina.  In 
consequence  the  body  of  the  uterus  becomes  smaller,  harder, 
more  globular  and  more  movable.  The  level  of  the  fundus 
also  rises  slightly,  as  the  presence  of  the  placenta  below 
prevents  the  uterus  from  sinking  into  the  pelvic  cavity.  For 
the  same  reason  the  supra-pubic  hollow  becomes  replaced 
by  a  slight  bulging,  indicating  the  position  of  the  placenta 
in  the  cervix.  Further  evidence  of  separation  may  be  found 
in  lengthening  of  the  umbilical  cord  outside  the  vulva. 
When  in  doubt  as  to  the  position  of  the  placenta,  the  uterus 
may  be  grasped  and  pushed  gently  downwards  and  back- 
wards into  the  pelvis  ;  if  the  placenta  is  still  attached  to 
the  uterus  the  cord  will  visibly  descend  with  it  and  retreat 
when  the  pressure  is  withdrawn.  If  separated,  little  or  no 
effect  will  be  observed. 

When  separated  the  placenta  can  usually  be  delivered  by 
a  voluntary  bearing-down  effort  on  the  part  of  the  patient, 
aided  by  the  medical  attendant  grasping  the  uterus  and 
pushing  it  downwards  and  backwards  in  the  axis  of  the 
pelvic  brim.  When  it  is  certain  that  the  placenta  has  left 
the  uterus,  pressure  upon  the  fundus  may  be  aided  by  gentle 
traction  upon  the  umbilical  cord  ;  this  must  never  be  done, 
however,  while  the  placenta  remains  attached  to  the  uterus. 
When  the  placenta  appears  at  the  vulva,  it  should  be  received 
in  the  hands  and  rotated  so  as  to  twist  the  membranes  which 
follow  it  into  a  spiral  or  rope,  which  gradually  comes  to  an 
end  and  slips  out  without  any  traction  having  been  made 
(Fig.  164).  In  this  way  tearing  of  the  membranes,  leading 
to  retention  of  a  portion  in  the  uterus,  is  avoided. 

If  after  waiting  for  at  least  half  an  hour  it  is  found  that 


334 


NORMAL  LABOUR 


the  placenta  still  remains  in  the  uterus,  an  attempt  may  then 
be  made  to  effect  its  expulsion  by  the  manipulation  of 
Crede,  often  called  '  expression  of  the  placenta.'  This 
consists  in  gently  rubbing  the  uterus  so  as  to  bring  about 
a  firm  contraction,  and  then  compressing  it  strongly  in  the 
grasp  of  one  or  both  hands,  at  the  same  time  pressing  the 
whole  organ  downwards  and  backwards  into  the  pelvic 
cavity  (Fig.  165).  The  partially  detached  placenta  can  in 
this  way  often  be  squeezed  out  of  the  uterus,  but  certain 
disadvantages  always  attend  this  manoeuvre — viz.,  (1)  por- 
tions of  the  placenta  and  of  the  chorionic  membrane 
may  be  left  attached  to  the  uterine  wall,  being  torn 
away  from  the  bulk  of  the  after-birth  ;  (2)  if  the  uterus  is 


Fig.  164. — Delivery  of  the  Membranes.     (Bumm. 


thus  compressed  during  relaxation,  the  process  of  inversion 
may  be  started  (see  p.  480).  It  must  therefore  be  clearly 
understood  that  the  Crede  method  is  not  to  be  employed 
merely  to  save  time,  but  only  in  cases  where  the  spontaneous 
separation  of  the  placenta  is  unduly  delayed.  With  the  aid 
of  anaesthesia,  the  placenta  can  always  be  delivered  by  this 
method,  unless  morbidly  adherent,  but  the  risk  of  retention 
of  a  portion  of  the  after-birth  is  naturally  greater  than  when 
anaesthesia  is  not  used. 

Prolongation  of  the  third  stage,  if  not  accompanied  by 
considerable  haemorrhage,  is  not  of  itself  disadvantageous  to 
the  patient.  There  is  therefore  no  need  for  hurry,  and  it 
must  be  borne  in  mind  that  natural  separation  of  the 
placenta  is  much  to  be  preferred  to  its  artificial  removal,  and 


MANAGEMENT 


335 


is  worth  waiting  for.  If  the  placenta  has  not  been  fully 
separated  in  half  an  hour  from  the  birth  of  the  child,  an 
attempt  may  be  made  to  deliver  it  by  expression.  Unless 
an  undue  amount  of  bleeding  occurs,  manual  removal  of  the 
placenta  by  passing  the  hand  into  the  uterus  (see  p.  515), 
should  not  be  undertaken  until  at  least  an  hour  has  elapsed. 
After  a  normal  labour  vaginal  douching  is  unnecessary, 


Fig.  165. — Expression  of  the  Placenta.     (After  Crede.) 


but  the  nurse  should  thoroughly  swab  the  vulva  with  an 
antiseptic  solution  {e.g.,  1-2,000  biniodide  of  mercury),  and 
all  perineal  tears  of  |  inch  or  more  must  be  immediately 
repaired.  The  uterus  should  be  continuously  massaged  for 
ten  to  fifteen  minutes  after  the  delivery  of  the  after-birth, 
and  gently  but  firmly  squeezed  to  expel  any  blood-clot  that 
may  have  remained  within  it  (Fig.  166).  Persistence  of 
haemorrhage  at  this  time  is  frequently  due  to  the  presence 


336  NORMAL   LABOUR 

of  a  clot  in  the  uterus,  and  when  this  has  been  squeezed  out 
the  bleeding  immediately  ceases.  The  presence  of  a  clot  in 
the  uterus  does  not  always  cause  bleeding,  but  it  invariably 
interferes  with  the  proper  retraction  of  the  uterus.  The 
empty,  fully  retracted  and  contracted  uterus  feels  densely 
hard  in  consistence,  and  irregular  in  outline  ;  when  the 
uterus  remains  globular  and  bulky  during  a  contraction,  and 
softish  in  consistence,  a  clot  is  probably  present.     If  a  clot 


Fig.  166. — Compression  of  the  Fundus  in  order  to  empty  the   Uteriis 
after  Delivery  of  the  Placenta.     (Edgar.) 

is  allowed  to  remain  in  the  uterus,  although  haemorrhage 
may  cease,  the  patient  is  liable  to  (1)  severe  after-pains  ; 
(2)  delayed  involution  ;  (3)  saprsemia.  Should  the  uterus 
still  tend  to  become  flabby,  a  dose  of  ergot  may  be  given, 
either  by  the  mouth  in  the  form  of  liquid  extract  of  ergot  5j, 
or  preferably  by  deep  intra-muscular  injection  into  the 
buttocks  in  the  form  of  injectio  ergotinse  hypodermica  (B.P.) 
or  '  aseptic  ergot.'  A  useful  alternative  to  ergot  is  pituitary 
gland  which  may  be  given  intra-muscularly  in  dose  of 
1  cc.  of  a  20  per  cent,  solution.     These  drugs  are  seldom 


POSTERIOR   POSITIONS  337 

required  by  a  primipara,  but  there  is  no  objection  to  their 
routine  use  in  multiparse.  Finally  an  abdominal  binder 
should  be  firmly  applied,  and  a  pad  of  sterihsed  absorbent 
cotton  or  gamgee  tissue,  or  of  corrosive-sublimate  wool, 
placed  over  the  vulva. 

Occipito-posterior  Positions  of  the  Vertex 

The  two  posterior  positions — third  and  fourth  taken 
together  are  much  less  frequent  than  the  two  anterior 
positions — ^first  and  second,  the  relative  proportions  being 
about  1  posterior  to  3  anterior  (see  p.  288). 

Mechanism. — The  mechanism  differs  from  that  of  the 
anterior  positions  in  two  particulars — (1)  flexion  is  deficient 
in  a  considerable  proportion  of  cases  ;  this  is  due,  (a)  to  a 
tendency  in  posterior  positions  towards  extension  of  the 
spine  and  therefore  of  the  head  ;  (6)  to  the  obstacle  offered 
by  the  pelvic  walls  to  the  descent  of  the  occipital  end  of  the 
head,  while  the  sincipital  end  is  free  ;  (2)  the  movement  of 
internal  rotation  is  unfavourably  influenced,  since  either 
{a)  a  long  movement  of  forward  rotation,  or  (b)  non-rotation, 
or  (c)  backward  rotation  must  occur.  If  the  uterus  acts 
powerfufly,  flexion  is  good,  and  the  head  and  pelvis  are  of 
normal  size,  the  occiput  will  rotate  forwards  ;  if,  however, 
flexion  is  deflcient,  or  the  pains  are  feeble,  or  if  the  head  is 
unusually  large,  or  the  pelvis  abnormally  small,  the  head  will 
remain  unrotated  (Fig.  101),  or  the  occiput  wifl  rotate  back- 
wards into  the  sacral  hollow.  When  forward  rotation  occurs 
the  case  terminates  in  the  same  way  as  an  anterior  position  ; 
but  when  non-rotation  or  backward  rotation  occurs  serious 
difficulty  is  met  with  in  the  expulsion  of  the  head.  Fig.  167 
shows  that  in  the  latter  position  the  shoulders  enter  the 
pelvic  cavity  along  with  the  head  ;  the  vagina  is  consequently 
over-distended  and  the  descent  of  the  presenting  part  is 
made  more  difficult.  The  part  of  the  head  which  in  this 
case  first  presents  at  the  vulva  is  the  region  of  the  anterior 
fontanelle  ;  the  occipito-frontal  diameter  (4|  inches)  is 
therefore  engaged  in  the  antero-posterior  diameter  of  the 
outlet.  The  vertex  first  passes  out  beneath  the  symphysis 
pubis  ;  then  the  perineum  stretches  and  the  occiput  slips 
over  it  ;  finally  the  face  passes  under  the  symphysis,  and 
E.M.  22 


338 


NORMAL  LABOUR 


thus  the  dehvery  of  the  head  is  completed  by  a  movement  of 
extension.  It  will  be  seen  that  much  longer  diameters  of 
the  foetal  head  are  engaged  than  when  the  occiput  is  anterior. 
Further,  the  wide  posterior  part  distends  the  permeum 
instead  of  emerging  between  the  labia,  and  the  risk  of  severe 
laceration  is  thus  much  increased. 

Diagnosis      and     General      Course      of      Labour. — The 


Fig.  167. — Illustrating  the  DifEciilty  in  Delivery  of  the  Head  in 
persistent  Occipito-Posterior  Positions. 

diagnosis  of  occipito-posterior  positions  has  been  already  in 
part  considered  (p.  312),  but  the  signs  found  on  external 
examination  may  be  briefly  recapitulated.  First,  m  thin 
subjects  the  abdomen  may  be  observed  to  be  flattened  and 
slightly  irregular,  instead  of  convex  and  uniform  as  in 
anterior  positions.  Secondly,  on  palpation  the  limbs  are 
felt  with  unusual  ease,  and  upon  both  sides  of  the  middle 
line.  Thirdly,  the  back  ma}^  be  difficult  to  locate.  Fourthly, 
the  wide,  irregular  frontal  end  of  the  head  may  be  felt  to  be 


POSTERIOR   POSITIONS  339 

directed  forwards.  Fifthly,  the  position  in  which  the  heart- 
sounds  are  heard  may  also  be  of  diagnostic  importance. 

Generally  speaking  labour  is  prolonged  and  often 
attended  with  pains  of  unusual  severity.  Both  the  first  and 
second  stages  are  prolonged,  and  it  is  probable  that  the 
uterus  acts  at  a  disadvantage  when  the  foetal  spine  is 
posterior  and  there  is  a  consequent  tendency  to  extension. 
The  descent  of  the  head  is  unusually  difficult  for  the  reasons 
just  stated,  and  in  the  second  stage  the  pains  often  become 
very  severe  and  almost  continuous,  although  the  labour 
makes  but  very  slow  progress. 

On  internal  examination  during  the  second  stage,  the 
finger  may  detect  the  anterior  fontanelle  lying  within  easy 
reach,  and  inclined  to  one  or  other  side  of  the  pelvis.  Further, 
a  careful  observer  may  notice  that  the  contour  of  the  present- 
ing part  is  abnormal,  as  will  be  understood  by  referring  to 
Figs.  131  and  133.  In  anterior  positions  the  presenting 
part  is  uniformly  convex  and  nearly  circular  in  outline  ;  in 
posterior  positions  it  is  flatter  and  irregularly  quadrilateral 
in  outline.  This  results  not  from  the  posterior  position, 
but  from  the  accompanying  deficiency  of  flexion.  When 
spontaneous  forward  rotation  occurs,  the  anterior  fontanelle 
recedes  out  of  reach  and  an  alteration  in  shape  of  the  present- 
ing part  may  become  quite  evident,  as  the  head  has  also 
become  better  flexed. 

The  course  of  the  second  stage  must  be  carefully  watched, 
and  special  attention  paid  to  the  descent  of  the  head,  and  to 
signs  of  rotation  in  one  or  other  direction.  More  frequent 
examinations  are  necessary  than  in  a  normal  labour,  and  the 
greatest  care  in  observing  the  antiseptic  routine  is  called  for. 
Non-rotation  is  usually  accompanied  by  non-descent ;  when 
the  head  begins  to  make  progress  it  usually  also  rotates,  and 
in  the  great  majority  of  instances  the  rotation  is  forwards, 
not  backwards.  Time  is  always  required  for  rotation,  and 
consequently  a  prolonged  second  stage  is  to  be  anticipated, 
and  any  attempt  to  unduly  hurry  the  conclusion  of  this 
stage  is  to  be  deprecated.  Interference  should  be  delayed 
until  it  becomes  clear  that  spontaneous  rotation  will  not 
occur,  and  the  usual  limits  of  this  stage  have  been  exceeded. 

Management. — When  a  posterior  position  has  been 
detected  during  the  last  weeks   of  pregnancy,   or  at  the 

22—2 


340  NORMAL  LABOUR 

commencement  of  labour,  an  attempt  may  be  made  to 
correct  it  by  external  abdominal  manipulations.  This  is 
done  by  locating  the  anterior  shoulder  below  and  the  breech 
above,  and  endeavouring  to  rotate  the  body  of  the  foetus 
towards  the  opposite  side.  If  the  anterior  shoulder  can  be 
pushed  across  the  middle  Hne  the  position  has  been  converted 
into  an  anterior.  In  a  primipara  this  manoeuvre  is  very 
difficult  owing  to  the  low  level  of  the  head  ;  in  a  multipara 
it  is  easier,  for  the  head  lies  higher.  If  corrected  before 
labour  the  posterior  position  may  recur. 

The  chief  object  of  the  management  of  labour  inoccipito- 
posterior  positions  is  to  convert  the  case  into  an  occipito- 
anterior. Since  nine  out  of  every  ten  cases  end  naturally 
in  forward  rotation,  little  need  be  done  until  it  becomes 
evident,  during  the  second  stage,  that  the  occiput  will  not 
come  forward.  The  main  cause  of  non-rotation  forward  is 
deficient  flexion,  and  it  is  obvious  that  if  the  head  could  be 
fully  flexed,  forward  rotation  might  occur  spontaneously. 
The  advice  often  given  to  promote  flexion  either  by  pushing 
up  the  sinciput  with  the  fingers,  or  by  puUing  down  the 
occiput  with  an  instrument  such  as  a  vectis  during  the 
pains,  although  theoretically  sound,  is  difficult  to  carry  out 
effectually.  Further  it  is  almost  always  found  that  exten- 
sion recurs,  the  reason  being  that  it  is  associated  with,  and 
largely  depends  upon,  extension  of  the  spine ;  and  the  former 
probably  cannot  be  corrected,  except  momentarily,  apart 
from  the  latter.  It  is,  however,  useful  to  arrange  that  the 
patient  should  lie  upon  the  side  which  will  so  affect  uterine 
obliquity  as  to  promote  flexion — the  left  side  in  the  third 
position,  the  right  side  in  the  fourth  position  (see  p.  294). 
To  push  the  uterus  across  the  middle  line  a  thickly -folded 
towel  may  be  placed  at  the  side  of  the  uterus  and  kejjt  in 
position  by  a  binder.  When  the  second  stage  has  lasted  for 
two  or  three  hours  and  there  is  no  sign  of  forward  rotation 
occurring,  it  is  better  to  terminate  the  case  with  forceps, 
first  rotating  both  the  head  and  trunk  of  the  child  so  as  to 
bring  the  occiput  and  the  back  to  the  front. 

Manual  rotation  is  not  always  easy  to  carry  out,  and  an 
anaesthetic  is  required  in  all  cases,  as  the  whole  hand  must  be 
introduced  into  the  vagina.  Sterihsed  rubber  gloves  should 
be  worn  by  the  operator.     Rotation  can  be  performed  more 


POSTERIOR   POSITIONS  341 

easily  with  the  patient  lying  on  her  back  than  in  the  side 
position  ;  the  buttocks  should  be  drawn  over  the  edge  of  the 
bed  and  the  legs  supported  by  an  assistant  or  held  in  a 
Clover's  crutch.  In  the  third  position  the  operator's  left  hand 
will  be  most  convenient  for  internal  use,  in  the  fourth 
position  the  right  ;  this  will  allow  of  the  rotation  being  done 
by  a  movement  of  pronation,  the  fingers  being  passed  up 
behind  the  occiput,  the  thumb  lying  in  front  of  it. 

Before  attempting  rotation  the  exact  position  of  the  head 
and  the  degree  of  extension  should  be  determined  ;  if 
flexion  is  very  dej&cient,  an  attempt  should  be  made  to  bring 
down  the  occiput,  either  with  a  blade  of  the  forceps  or  by 
passing  the  fingers  above  it  up  to  the  neck  and  then  pulling 
the  occiput  downwards.  The  more  the  head  is  flexed  the 
easier  will  it  be  to  rotate  it.  Then  the  head  is  firmly  grasped 
in  the  manner  just  described,  and  the  occiput  turned  forwards 
towards  the  symphysis.  It  is  desirable  to  rotate  the  trunk 
as  well  as  the  head,  otherwise  the  neck  will  be  twisted  and 
the  occiput  will  tend  to  return  to  its  faulty  position  as  soon 
as  it  is  released  from  the  fingers.  Trunk  rotation  may  be 
assisted  by  the  operator  finding  the  anterior  shoulder  with 
his  disengaged  hand  and  endeavouring  to  push  it  over 
towards  the  middle  line,  while  the  internal  hand  is  rotating 
the  head.  Or  in  a  difficult  case  the  internal  fingers  may  be 
passed  upwards  above  the  head  to  the  anterior  shoulder, 
which  is  then  forcibly  pushed  across  the  middle  line  to  the 
opposite  side.  When,  however,  little  liquor  amnii  remains  in 
the  uterus,  rotation  of  the  trunk  is  almost  impossible,  and 
it  is  then  best  to  rotate  the  head  as  much  as  possible,  and, 
while  the  hand  keeps  it  in  its  corrected  position,  to  apply 
the  forceps  immediately,  before  the  head  can  return  to  its 
faulty  position.  With  the  patient  lying  on  her  back  the  right 
blade  should  be  first  introduced  when  dealing  with  a  third 
position,  as  this  will  effectually  prevent  the  occiput  from  again 
rotating  backwards.  In  the  fourth  position  the  left  blade 
should  be  first  applied.  If  manual  rotation  should  entirely 
fail  the  forceps  must  be  applied  to  the  non-rotated  head, 
but  serious  lacerations  of  the  pelvic  floor  involving  the 
rectum  will  probably  occur  in  a  primipara  ;  in  a  multipara 
there  may  be  no  serious  injury  if  the  head  and  the  pelvis  are 
of  normal  size. 


342 


NORMAL  LABOUR 


In  a  multipara  with  feeble  uterine  contractions,  the  head 
may  completely  fail  to  engage  in  the  brim  ;  labour  advances, 
the  cervix  dilates,  the  membranes  rupture,  and  no  advance 
of  the  head  occurs,  which  remains  freely  movable  above 
the  level  of  the  pelvic  brim.  This  is  the  most  difficult  example 
of  an  occipito-posterior  position  to  deal  with.  The  apphca- 
tion  of  forceps  to  the  head  above  the  brim  is  the  most 
difficult  operation  in  obstetrics.  Li  addition  the  head  must 
be  rotated  before  the  forceps  is  applied,   and  rotation  is 


Fig.  168. — Usual  Moulding  in  Occipito-Posterior  Position. 
(Galabin  and  Blacker.) 


much  more  troublesome  with  the  head  at  this  high  level 
than  when  it  has  reached  the  pelvic  cavity.  The  best 
method  of  delivery  in  such  circumstances  is  internal  version 
if  the  child  is  ahve  ;  craniotomy  may  be  performed  if  it  is 
dead. 

The  moulding  of  the  foetal  head  in  occipito-posterior 
positions  differs  somewhat  from  that  m  anterior  positions 
(Fig.  168).  The  compression  of  the  occipito  frontal  plane 
is  exaggerated,  and  the  frontal  bones  are  more  markedly 
displaced  beneath  the  parietal  bones.  The  position  of  the 
caput  has  been  already  mentioned. 


Part   IV 

ABNOEMAL    LABOUR 

In  this  section  the  following  conditions  will  be  considered 
(I.)  Abnormal  Presentations. 

Face  and  brow  presentations. 
Breech  or  pelvic  presentations. 
Transverse  or  shoulder  presentations. 
Twin  labour. 

Prolapse  of  the  cord  and  limbs. 
(II.)  Abnormal  Conditions  of  the  Maternal  Passages, 
(a)  The  bony  pelvis. 

Pelvic  contraction. 
Tumours  of  the  pelvic  bones. 
(&)  The  soft  parts. 

Ovarian  tumours. 
Uterine  tumours. 
Rigidity  of  the  cervix. 
Rigidity  of  the  pelvic  floor. 
(III.)  Abnormalities  in  the  Action  of  the  Uterus. 
Precipitate  labour. 
Uterine  inertia. 
Tonic  uterine  contraction. 
Ante-partum  rupture  of  the  membranes,. 
(IV.)  Obstructed  Labour. 
(V.)  Maternal  Injuries  in  Parturition. 
Rupture  of  the  uterus. 

,,         ,,     „    cervix  and  vagina. 
,,         ,,     ,,    perineum  and  vulva. 
Hsematoma. 
Inversion  of  the  uterus. 
(VI.)  Ante-partum  Hoemorrhage. 
(VII.)  Non-expulsion  of  the  Placenta. 
(VIII.)  Post-partum  Haemorrhage. 
(IX.)  Labour  complicated  by  Eclampsia. 


344  ABNORMAL   LABOUR 

Face  and  Brow  Presentations 

These  presentations  are  brought  about  by  complete 
extension  of  the  head  upon  the  spinal  column,  the  occiput 
resting  against  the  cervical  vertebrae,  and  the  chin  bemg 
widely  separated  from  the  chest  wall  (Fig.  169).  They  occur 
in  about  1  in  300  labours  (0'3  per  cent.  Queen  Charlotte's 
Hospital  statistics).  Little  is  known  of  the  causes  of  this 
complete  extension  of  the  head,  but  it  is  beheved  that  the 
following  may  be  either  essential  or  contributory  causes  : 

1.  Extreme  obliquity  of  the  uterus. 

2.  Pelvic  contraction. 

3.  Large  size  of  the  foetus. 

4.  Dolicho-cephalic  foetal  skull  (long  antero-posterior 
diameters). 

5.  Congenital  malformations — e.g.  goitre  and  anen- 
cephaly. 

6.  Multiparity. 

7.  Placenta  prsevia  and  hydramnios. 

Face  Presentation. — This  presentation  is  very  rarely  met 
with  in  'pregnancy,  but  appears  to  be  usually  produced  at 
the  onset  of  labour,  by  conditions  which  prevent  the  easy 
entrance  of  the  vertex  into  the  pelvic  brim.  Causes  1,  2, 
and  3  therefore  need  no  comment  ;  the  influence  of  uteruie 
obliquity  in  causing  extension  of  the  head  has  been  referred 
to  on  p.  294.  Considerable  doubt  exists  whether  the  elonga- 
tion of  the  antero-posterior  diameters  of  the  foetal  head, 
which  is  often  met  with  in  face  cases,  is  primary  or  secondary, 
many  observersmaintainingthat  it  is  produced  during  labour, 
and  is  therefore  the  effect,  not  the  cause,  of  the  presentation. 
The  congenital  malformations  mentioned  have  been  respon- 
sible for  the  very  rare  instances  in  which  face  presenta- 
tion has  been  recognised  before  labour.  Congenital  goitre 
is  not  micommon  in  countries  where  goitre  is  endemic,  but 
elsewhere  it  is  extremely  rare.  Face  presentation  results 
from  the  mechanical  obstacle  to  flexion,  and  is  really  an 
advantage,  since  it  protects  the  gland  from  mjurious  pressure 
from  the  chin.  The  anencephahc  head  lies  naturally  in 
full  extension.  Statistics  show  that  this  presentation  occurs 
in  primigravidae  and  multiparse  respectively  in  the  proportion 
of  two  to  three,  and  repeated  presentation  of  the  face  has 


FACE   CASES 


345 


been  observed  in  successive  labours  in  the  same  patient. 
Placenta  praevia  and  hydramnios  favour  all  kinds  of 
abnormal  presentation,  but  not  especially  that  of  the  face. 

The  attitude  of  the  foetus  is  shown  in  Fig.  169.  It  will  be 
noticed  that,  while  the  limbs  are  flexed,  the  trunk  and  spine 
are  extended  ;  the  outline  of  the  back  is  flat,  not  convex, 
and  is  broken  below  by  the  prominence  formed  by  the  occiput 
when  the  head  is  completely  extended.  The  interval  seen 
between  the  knees  and  elbows  is  of  course  caused  by  the 


Fig.  169.— Face  Presentation  :  First  Position. 
(Eibemont-Dessaignes  and  Lepage.) 

extension  of  the  spine.    Four  positions  are  distinguished  as 
follows,  the  chin  being  the  denominator  of  the  presentation  : 

1st  position  .  Eight  mento-posterior  ,  R.M.P. 

2nd       ,,  .  Left  mento-posterior  .  L.M.P. 

3rd        ,,  .  Left  mento-anterior  .  .  L.M.A. 

4th        ,,  :  Eight  mento-anterior  .  E.M.A. 

The  first  position  is  by  far  the  commonest,  then  comes  the 
third  ;  the  second  and  fourth  are  rare.  The  face  therefore 
engages  in  the  right  oblique  diameter  of  the  brim  in  a  very 
large  preponderance  of  cases,  just  as  does  the  vertex.  The 
relation  of  the  head  to  the  pelvis  at  the  commencement  of 
labour  is  shown  in  Figs.  169  and  170.     By  comparison  with 


346 


ABNORMAL  LABOUR 


Figs.  131  and  132  it  will  be  seen  that  the  presenting  part 
occupies  a  comparativel}^  small  part  of  the  pelvic  space.     In 


Fig.  170. — Face  Presentation  :  Thii-d  Position. 

comparing  the  positions  of  the  face  with  those  of  the  vertex, 
it  will  be  observed  that  they  precisely  correspond  in  respect 


Fig.  ITI.- — Face  Presentation  :  Fourtli  Position. 

of  the  position  of  the  back   of  the  foetus  ;    in  the  first  and 
second   positions   it   is   anterior,   in   the   third   and   fourth 


FACE   CASES  347 

posterior,  in  both  presentations.  Thus,  if  in  a  first  vertex 
position  the  head  became  completely  extended,  a  first 
position  of  the  face  would  result  from  it. 

Diagnosis. — Abdominal  palpation  should  be  carried  out 
in  the  systematic  manner  described  in  connection  with 
nornial  labour.  The  actual  shape  of  the  foetal  ovoid  will 
attract  attention  if  the  back  is  anterior  (Fig.  169)  ;  the  head 
in  this  case  will  lie  well  above  the  pelvic  brim  at  the  com- 
mencement of  labour,  even  in  a  primipara,  and  the  prominent 
occiput,  with  the  sulcus  between  it  and  the  back,  can  be 
palpated.  It  is  not  nearly  so  easy  to  make  out  the  entire 
surface  of  the  back  as  in  a  vertex  presentation,  for  a  con- 
siderable interval  exists  between  the  upper  dorsal  region  of 
the  back  and  the  maternal  abdominal  wall.  In  palpating 
from  the  fundus  downwards,  the  outline  of  the  back  is  there- 
fore lost  before  the  occipital  prominence  is  reached.  When 
the  back  is  posterior,  the  prominent  occiput  is  not  readily 
accessible  to  palpation  ;  but  the  small  parts  representing 
the  limbs  are  extremely  easily  felt.  The  two  most  important 
points  on  palpation  therefore  are  the  indistinct  outline  of 
the  back  and  the  deep  sulcus  between  the  occiput  and  the 
cervical  spine.  Auscultation  affords  little  help  in  diagnosis  ; 
the  heart  is  heard  at  a  somewhat  higher  level  than,  but  other- 
wise in  the  same  position  as,  in  vertex  presentations  ;  and 
in  anterior  positions  of  the  chin  the  sounds  are  unusually 
distinct,  as  the  chest  is  thrown  forwards  against  the  abdo- 
minal wall. 

Vaginal  examination  at  the  commencement  of  labour  is 
indecisive  ;  the  presenting  part  lies  high  and  is  ill-defined  in 
outline  ;  it  will  often  be  impossible  to  distinguish  it  from  the 
breech.  When  the  first  stage  is  more  advanced,  the  bag  of 
waters  will  be  noticed  to  be  unusually  large,  and  premature 
rupture  of  the  membranes  is  fairly  common.  The  large  size 
of  the  bag  is  due  to  the  fact  that,  as  the  face  does  not  fill  the 
lower  segment  so  well  as  does  the  vertex,  a  larger  amount  of 
liquor  amnii  descends  below  the  presenting  part.  Great 
care  should  be  taken  not  to  rupture  the  membranes  acci- 
dentally, but  during  the  intervals  between  the  pains  it  will 
probably  be  possible  by  gentle  touch  to  recognise  {e.g.  in  the 
third  position)  the  frontal  suture  leading  anteriorly  to  the 
orbital  ridges  and  to  the  nose  (Fig.   170).     At  a  still  later 


348 


ABNORMAL  LABOUR 


stage,  when  extension  of  the  head  has  become  complete  and 
the  cervix  is  further  dilated,  it  will  be  found  that  the  orbital 
ridges,  mouth,  and  chin  can  all  be  reached  and  recognised  by 
the  finger.  The  direction  of  the  chin  will  of  course  indicate 
which  of  the  four  positions  of  the  face  is  present  (see  Figs. 
172  and  173).  During  the  second  stage  diagnosis  by  vaginal 
examination  may  become  very  difficult  owing  to  the  tume- 
faction of  the  brow,  cheeks,  and  lips  (caput  succedaneum), 
which  results  from  pressure  around  the  girdle  of  contact. 


Pig.   172. — Face  Presentation,      a.  Pirst  Position,     h.  Second  Position. 
(Faraboeuf  and  Varniei'.) 

The  aiTow  indicates  the  line  of  forward  rotation.    Patient  in  usual  obstetric  position. 

The  orbital  ridges  become  obscured  and  the  mouth  opens, 
but  by  passing  the  finger  into  the  mouth  the  alveolar  processes 
can  always  be  recognised,  and  this  is  accordingly  a  most 
important  diagnostic  point.  The  nose  undergoes  Httle 
alteration,  and  consequently  the  nares  with  the  septum 
between  them  may  still  be  recognisable  (Fig.  178)  when  the 
other  parts  have  become  completely  obscured  by  swelling. 
Mechanism. — (1)  Extension  in  a  face  presentation  cor- 
responds with  flexion  in  a  vertex.  It  is  produced  at  the 
onset  of  labour  by  the  conditions  named  above,  and  is  pro- 
gressive, being  frequently  incomplete  until  the  head  has 


FACE  CASES 


349 


descended  well  into  the  pelvic  cavity  (Fig.  174).  When 
completely  extended  the  diameter  of  engagement  is  the  sub- 
mento-bregmatic  (3f  inches),  which  hes  in  one  of  the  oblique 
diameters  of  the  brim  (4f  inches)  ;  when  incompletely 
extended  a  longer  diameter,  the  sub-mento-vertical  (4| 
inches),  becomes  engaged.  The  greatest  transverse  dia- 
meter of  the  face  (bi-malar)  is  considerably  less  than  that 
of  the  vertex,  the  bi-parietal.     There  is  thus  no  difference 


Fig.  173. — Face  Presentation,     a.  Thiid  Position,     h.  Fourth  Position. 
(FarabcBuf  and  Varnier.) 

The  arrow  indicates  the  hne  of  forward  rotation.    Patient  in  usual  obstetric  position. 


between  a  fully-flexed  vertex  and  a  fully-extended  face  in 
the  length  of  the  diameter  of  engagement,  while  the  trans- 
verse diameter  is  smaller  ;  but  it  must  be  remembered  that 
while  the  size  of  the  vertex  may  be  reduced  by  moulding,  the 
bones  of  the  face  are  incompressible.  Deficient  extension 
influences  a  face  presentation  unfavourably  by  introducing 
a  longer  diameter  of  engagement. 

(2)  Internal  rotation  is  probably  controlled  entirely  by 
the  slope  of  the  pelvic  floor  ;  when  the  head  is  completely 
extended  the  chin  is  the  lowest  part,  and  therefore  it  first 
reaches  the  pelvic  floor  and  is  directed  by  the  slope  down- 


350 


ABNORMAL  LABOUR 


wards  and  forwards  under  the  pubic  arch.  Since  the  most 
frequent  position  is  the  right  mento-posterior,  this  usually 
involves  a  long  movement  of  rotation  (about  fths  of  a  circle) 


Fig.  174. — Face  Presentation  :  Third  Position.  The  completely 
extended  face  has  descended  into  the  jDelvic  cavity,  and  still 
lies  in  the  right  oblique  diameter.  The  head  is  elongated 
antero-posteriorly. 


around  the  right  wall  of  the  pelvis.  If  the  head  is  imperfectly 
extended  so  that  the  sinciput  is  lower  than  the  chin,  the 
latter  will  rotate  backwards  into  the  sacral  hollow  {persistent 
mento-posterior    position).     Natural    delivery    is    then    im- 


FACE   CASES 


351 


possible,  except  in  the  case  of  a  very  small  or  macerated 
foetus. 

(3)  Flexion. — After  forward  rotation  of  the  chin  has 
occurred,  the  head  becomes  disengaged  by  a  movement  of 
flexion,  which  thus  takes  the  place  of  extension  in  a  vertex 


Fig.  175. — Face  Presentation.   Forward  Rotation  of  the  Chin  has  occurred.' 


presentation.  The  chin  first  emerges  under  the  symphysis 
pubis  ;  then  the  face,  forehead,  vertex,  and  lastly  the 
occiput  pass  successively  over  the  perineum  (Fig,  176).  It 
is  important  that  the  chin  should  be  brought  well  forwards 
under  the  pubic  arch  before  flexion  occurs,  otherwise  the 
mento-vertical  diameter  (5|  inches)  must  pass  through  the 
outlet  instead  of  the  sub-mento-vertical  (4|  inches).     It  is 


352 


ABNORMAL  LABOUR 


therefore  clear  that  the  passage  of  the  head  through  the 
vulva  in  a  face  presentation  is  always  more  difficult  than  in  a 
vertex  presentation,  owing  to  the  greater  length  of  the 
diameters  of  engagement. 

(4)  Restitution  and  External  rotation  are  brought  about  by 


Pig.  176. — Face  Presentation.     The  movement  of  internal  rotation  has 
occurred,  and  the  face  is  passing  through  the  outlet  by  a  movement 
.   of  flexion. 

the  same  causes,  and  follow  the  same  rule  with  regard  to 
direction,  as  in  vertex  presentations. 

The  most  favourable  positions  in  presentation  of  the  face 
are  those  in  which  the  chin  is  anterior  (third  and  fourth).  In 
these  the  back  is  posterior,  and  the  effect  of  its  apposition 
with  the  maternal  vertebral  column  is  to  extend  the  spiue, 
and    thus    promote    extension    of    the    head — the    normal 


FACE   CASES  353 

mechanism  of  this  presentation.  In  addition,  the  movement 
of  forward  rotation  of  the  chin  is  much  shorter  than  in  the 
first  and  second  positions. 

The  effects  of  labour  upon  the  head  of  the  foetus  are  very 
marked.  Tlie  tumefaction  of  the  face  has  been  already 
referred  to  ;  it  is,  of  course,  due  to  the  formation  of  the 
caput  succedaneum,  but  in  this  case  the  effusion  is  usually 
sanguinolent,  giving  the  appearance  of  considerable  bruising, 
often  accompanied  with  small  bullae  containing  blood- 
stained fluid.     The  effusion,  as  a  rule,  becomes  absorbed  in 


Fig.  177. — Moulding  of  the  Head  after  Face  Presentation. 
(After  Budin.) 

a  few  days  after  birth,  and  the  skin  rapidly  regains  its 
normal  colour.  The  changes  produced  during  labour  in  the 
shape  of  the  skull  are  also  shown  in  Fig.  177.  The  vertex 
becomes  flattened  by  being  compressed  against  the  pelvic, 
wall,  thus  reducing  the  sub-occipito-bregmatic  and  sub- 
mento-bregmatic  diameters,  while  the  occipito-frontal  dia- 
meter becomes  considerably  lengthened,  the  plane  of  prin- 
cipal compression  being  the  plane  of  the  sub-mento-breg- 
matic  diameter. 

The  mechanism  of  labour  in  a  face  presentation  may  be 
said  to  differ  from  that  in  a  vertex  mainly  in  the  greater 
difficulty  of  the  expulsion  of  the  head  and  the  more  serious 

E.M.  23 


154 


ABNORIVIAL  LABOUR 


results  of  backward  rotation.  A  face  presentation,  as  a  rule, 
brings  no  more  risk  to  the  mother  than  a  vertex  ;  labour  is, 
however,  longer,  because  the  face  is  a  less  efficient  dilator 
and  the  membranes  are  more  Hable  to  rupture  early  ;  further, 
as  repeated  examinations  may  be  necessary  for  diagnosis, 
the  strictest  antiseptic  precautions  are  called  for.  There 
is  some  increase  of  risk  to  the  child,  owing  mainlj^  to  the 
comparative  frequency  of  such  complications  as  premature 


Fig.  178.— Delivery  of  the  Head  in  Face  Presentation:  Movement  of 
Flexion.     (Eibemont-Dessaignes  and  Lepage.) 

The  swelling  of  the  lips  and  the  unaltered  condition  of  the  naves  are  shoivn. 

rupture  of  the  membranes,  and  prolapse  of  the  cord  or  of 
•  one  of  the  hands. 

Management  of  Face  Presentations. — The  possibility  of 
the  pelvis  being  contracted  should  always  be  borne  in 
mind  in  connection  with  face  presentations.  Since  the 
majority  of  cases  termmate  naturally  by  forward  rotation 
of  the  chin  and  spontaneous  disengagement  of  the  head, 
interference  is  not  alwaj-s  called  for.  It  is  therefore  the 
wisest  plan  to  leave  face  presentations  alone,  and  interfere 
only  under  certain  well-defined  conditions.     The  membranes 


FACE   CASES 


355 


should  be  very  carefully  preserved,  for  the  face  is  an  in- 
efficient dilator  ;  therefore  vaginal  examinations  should  be 
made  with  special  care,  and  the  patient  kept  lying  down 
during  the  greater  part  of  the  first  stage.  During  the  second 
stage  what  is  possible  should  be  done  to  promote  extension  ; 
forward  rotation  of  the  chin  will  then  inevitably  follow. 
Use  may  be  made  of  uterine  obliquity  in  promoting  extension 
by  directing  the  patient  to  lie  upon  the  side  opposite  to  that 
on  which  the  chin  has  been  located  ;  but  upward  pressure 
with  the  fingers  on  the  forehead  or  downward  traction  on 
the  chin,  if  attempted,  must  be  appHed  very  carefully, 
as  the  face  may  be 
seriously  injured  or  the 
eyes  infected.  If  the 
chin  rotates  back- 
wards, or  if  forward 
rotation  is  much  de- 
layed, the  best  treat- 
ment is  to  anaesthetise 
the  patient,  and  then 
rotate  the  head  and 
trunk  so  as  to  bring 
the  chin  forwards,  in 
the  manner  already 
described  in  connec- 
tion with  posterior 
positions  of  the  vertex 
(p.    340).       The    chin 

should  then  be  pulled  down  until  the  face  is  completely 
extended,  and  the  head  immediately  dehvered  with  forceps. 
If  forward  rotation  cannot  be  accomplished  in  this  way,  it 
may  prove  possible  to  dehver  with  axis-traction  forceps  in 
the  case  of  a  small  foetus,  even  in  the  persistent  mento- 
posterior position.  If,  however,  this  should  fail,  cranio- 
tomy will  probably  be  required. 

If  the  presentation  is  complicated  by  prolapse  of  the  cord 
or  of  a  hand,  the  best  treatment  is  to  perform  version  by 
either  the  combined  or  the  internal  method  (p.  675)  ;  the 
object  of  this  interference  is  to  obviate  the  increased  foetal 
risks  of  these  complications. 

It  has  been  sometimes  advised  when  a  face  presentation 

23—2 


Fig.  179. — Face  Presentation  :  the  Head 
of  the  Child  after  Delivery.  (Ribe- 
mont-Dessaignes  and  Lepage.) 


356  ABNORMAL   LABOUR 

is  recognised  early  in  labour,  before  rupture  of  the  mem- 
branes, that  an  attempt  should  be  made  to  convert  it  into  a 
vertex  by  flexing  the  head.  It  may  be  said  that  this  pro- 
cedure is  unnecessary,  difficult  to  carry  out,  and  if  not  com- 
pletely successful  it  does  harm  by  bringing  about  the  most 
unfavourable  of  all  cephalic  presentations — viz.,  the  hroiv. 
The  essential  difficulty  is  that  both  the  spine  and  the  head 
must  be  flexed,  or  the  face  presentation  mil  immediately 
recur.  Many  methods  of  attempting  this  correction  have 
been  described  by  Baudelocque,  Schatz,  Thorn,  and  others, 
but  it  may  be  said  that  they  are  only  suitable  for  the  practice 
of  lying-in  hospitals,  and  cannot  be  recommended  for  general 
adoption.  As  a  routine  principle  face  presentations  should 
be  left  to  nature  unless  the  conditions  exist  which,  as  has 
been  mentioned,  call  for  the  performance  of  version.  When 
face  presentation  occurs  mth  a  contracted pehas,  the  manage- 
ment of  the  labour  will  be  governed  mainly  by  the  shape 
and  size  of  the  pelvis. 

Brow  Presentations. — When  the  head  lies  midway 
between  the  attitude  of  complete  flexion  and  that  of  com- 
plete extension,  the  brow  presents  at  the  brim,  and  the 
longest  diameter  of  the  head  (mento-vertical,  5^  inches) 
becomes  the  diameter  of  engagement.  The  shape  and  size 
of  the  mento-vertical  plane,  as  shown  in  Fig.  180,  make  the 
passage  of  the  normal-sized  head  through  the  pelvis,  when 
presenting  in  this  way,  well-nigh  impossible.  Probably  this 
presentation  should  be  regarded  as  a  sub-variet}^  of  the  face 
presentation,  due  to  arrest  midway  of  the  process  of  extension. 

Diagnosis. — Presentation  of  the  brow  usually  passes 
unrecognised  until  labour  is  well  advanced.  The  external 
examination  may  show  nothing  abnormal,  while  vaginally 
the  presentation  will  be  mistaken  for  a  vertex  until  the 
cervix  is  well  dilated.  The  brow  presentation  may  then  be 
recognised  by  the  presence  of  the  anterior  fontanelle  at  one 
end  of  the  presenting  part  and  the  orbital  ridges  at  the  other. 
When  the  mouth  and  chin  can  be  felt,  the  presentation  is  a 
face.  It  is  fortunate  that  this  presentation  is  rare  (1  in 
1,500  to  2,000  labours),  for  natural  delivery  is  impossible 
unless  the  foetus  is  undersized. 

Mechanism.— The  orbital  ridges  maj'  be  either  anterior 
or  posterior  in  brow  presentations,  the  former  being  the  more 


FACE   CASES 


n57 


favourable.  An  anterior  brow  may  be  delivered  naturally 
if  the  head  is  small,  the  pelvis  is  of  normal  size,  and  the 
uterus  is  acting  powerfully.  Moulding  then  occurs,  which 
results  in  marked  compression  of  the  mento-vertical  dia- 
meter, and  compensating  elongation  of  the  occipito-frontal  ; 
this  causes  great  bulging  of  the  frontal  bones.  The  head 
then  descends  with  the 
superior  maxilla  com- 
pressed against  the  pu- 
bes,  the  occiput  lying  in 
the  sacral  hollow  ;  the 
frontal  region  first  ap- 
pears at  the  vulva,  and 
is  followed  by  the  vertex 
and  occiput,  the  face  and 
chin  being  disengaged 
from  the  pubes  the  last 
of  all.  This  method  ac- 
cordingly resembles  the 
delivery  of  the  vertex 
in  face  to  pubes  cases 
as  shown  in  Fig.  167, 
but  in  the  case  of  the 
brow  presentation  the 
head  is,  of  course,  more 
extended.  Very  con- 
siderable deformity  of 
the  head,  consisting  of 
flattening  of  the  vertex 
and  bulging  of  the  fore- 
head, results.  In  pos- 
terior positions  of  the 
brow,  forward  rotation 
may  occur,  when  the 
case  ends  in  the  manner  just  described  ; 
not  occur  natural  delivery  is  impossible. 

Management. — It  is  probable  that  every  face  presenta- 
tion passes  through  the  preliminary  stage  of  a  brow  presenta 
tion;  cases  are  accordingly  observed  to  undergo  spontaneous 
transformation  to  a  facs.     The  persistence  of  brow  presenta- 
tion, however,  involves  considerable  risk  both  to  mother  and 


Fig.   180.— The   Position   and   Shape  of 
the  Meiito-vertical  Plane.     (Edgar.) 


if  rotation  dees 


358  ABNORMAL   LABOUR 

child  ;  therefore,  if  detected  early  in  labour,  either  before  or 
soon  after  rupture  of  the  membranes,  version  should  be 
performed,  and  the  case  converted  into  a  breech.  If  labour 
is  too  advanced  for  version  to  be  performed,  an  attempt  may 
be  made  either  to  flex  the  head,  producing  a  vertex  presenta- 
tion, or  to  extend  it  completely,  producing  a  face  ;  the  latter 
is  easier  to  perform,  but  great  care  must  be  taken  not  to 
injure  the  face  or  eyes.  If  the  head  is  fixed  in  the  brim,  it 
must  be  allowed  to  continue  as  a  brow  presentation,  and  an 
attempt  made  to  deliver  with  forceps  as  soon  as  the  cervix 
is  sufficiently  dilated,  but  version  in  all  cases  offers  the 
safest  method  of  dealmg  with  brow  presentations. 

Breech  or  Pelvic  Presentations 

When  the  pelvic  extremity  of  the  foetal  ovoid  lies  at  the 
brim,  and  the  cephalic  extremity  at  the  fundus,  the  presenta- 
tion is  called  a  breech.  If  the  normal  attitude  of  flexion  is 
unaltered  the  presenting  part  will  consist  of  the  buttocks 
with  the  external  genital  organs,  and  one  or  both  feet,  the 
latter  lying  somewhat  above  the  former  ;  this  is  called  the 
complete  breech  (Fig.  181).  Some  alteration  of  the  normal 
attitude  is,  however,  not  uncommon.  The  most  frequent  is 
extension  of  the  legs  upon  the  thighs,  bringing  the  feet  up  to 
the  sides  of  the  neck  ;  this  is  called  the  incornplete  breech  ivith 
extension  of  the  legs  (Fig.  182).  Sometimes,  however,  the 
thighs  are  extended  and  the  legs  flexed,  bringing  the  knees 
down  into  the  brim  ;  or,  finally,  both  the  legs  and  the  thighs 
may  be  partially  extended,  bringing  down  the  feet.  The 
two  latter  are  often  termed  knee  and  footling  presentations , 
but  they  must  of  course  be  regarded,  not  as  distinct 
from,  but  as  varieties  of,  the  incomplete  breech  presen- 
tation. Breech  presentations  may  therefore  be  classified 
thus  : 

A.  Complete  Breech  Presentation. 

B.  Incomplete  Breech  Presentation. 

(1)  With  extended  legs. 

(2)  With  extended  thighs. 
(a)  Knee  (legs  flexed). 

(6)  Footling  (legs  extended). 


BREECH   PRESENTATIONS 


359 


Occurrence. — Breech  presentations  occur  approximately 
in  1  in  30  (3"3  per  cent.)  of  all  labours;  if,  however, 
premature  labours  are  excluded,  the  proportion  falls  to 
1  in  60,  showing  that  this  presentation  is  much  more  frequent 
in  premature  than  in  full-time  labours.  It  is  usually  stated 
that  breech  presentations  occur  somewhat  more  frequently 
in  multiparee  than  in  primigravidse,  but  recent  statistics  from 
the  Clinique  Baudelocque  (Paris)  show  that,  excluding  cases 
of  contracted  pelvis  and  of  premature  labour,  the  ijreponder- 
ance  lies  Tdecidedly    with    primigravidse.      The  incomplete 


Os  int.1  Cervical 
Osext.f  canal. 

Utero -vesical 
peritoneum. 

Bladder. 
Symphysis  Pubis. 
Vagina. 

Fig.  181. — Complete  Breech  Presentation  before  Labour. 
From  a  Frozen  Section.     (Walcleyer.) 


breech  presentation,  in  one  or  other  of  its  forms,  is  commoner 
than  the  complete. 

Causes. — It  is  customary  to  ascribe  breech  presentation 
to  disturbance  of  the  conditions  which  produce  vertex 
presentation  (see  p.  286).  Thus  the  cephalic  end  of  the  foetal 
ovoid  may  be  larger  than  the  pelvic  end,  as  in  Tiydroce'phalus  ; 
the  lower  uterine  segment  may  be  unduly  distended,  and 
approximately  equal  in  size  to  the  fundus,  as  in  hydramnios  ; 
the  centre  of  gravity  of  the  premature  foetus  lies  near  the 
centre  of  the  body,  and  therefore  the  tendency  to  lie  head 


360 


ABNORMAL  LABOUR 


downward  in  the  liquor  amnii  is  lost  in  premature  labours. 
In  addition,  placenta  prcevia  favours  the  occurrence  of  breech 
presentation,  for  the  presence  of  the  placenta  in  the  lower 
uterine  segment  diminishes  the  capacity  of  this  part  of  the 
uterus,  and  so  tends  to  displace  the  head  when  presenting. 


Fig.  182. — Breech  Presentalion  with  Extended  Legs. 
From  a  Frozen  Section,     (liarboirr.) 


Pelvic  contraction  produces  much  the  same  result.  It  must^ 
however,  be  admitted  that  many  breech  presentations  occur 
in  which  none  of  these  conditions  are  present,  and  they  must 
therefore  be  regarded  as  merely  contributory  causes. 

Four  positions  of  the  breech  presentation  are  described, 
the  sacrum  being  the  denominator  : 


BREECH   CASES 


361 


1st  position  .  .  Left  sacro- anterior  .  .  L.S.A. 

2ud       .,       .  .  Eight  ?acro-anterior  .  R.S.A. 

3rd        ,,        .  .  Eight  sacro-posterior  E.S.P. 

4th        ,,       .  .  Left  sacro-posterior  .  L.S.P. 


(Fig.  183). 


Diagnosis. — Abdominal  palpation  should  be  carried  o  at  in 
the  usual  systematic  manner  described.  It  is  much  easier  to 
recognise  a  breech  presentation  by  abdominal  than  by  vaginal 
examination  in  the  earlier  stages  of  labour.  The  pelvic 
grip  will  show  that  the  foetal  pole  which  occupies  the  lower 
part  of  the  uterus  does  not  possess  the  characteristics  of  the 


Fig.  183. — Breech  Presentation:  First 
Position.     (Faraboeuf  and  Varnier.) 

head  ;  it  is  softer,  more  irregular,  and  less  defined  in  outline  ; 
it  usually  lies  above  the  level  of  the  brim,  and  small  parts 
moving  spontaneously  may  be  felt  near  it.  The  fundus 
must  next  be  palpated  with  great  care,  when  the  head  will  be 
recognised  by  the  points  mentioned  on  p.  314.  It  will 
usually  be  found,  not  in  the  middle  line,  but  at  one  or  other 
side  of  the  fundus.  It  is  easier  to  palpate  its  general  outline 
than  when  the  head  lies  at  the  brim  ;  owing  to  the  greater 
capacity  of  the  uterine  cavity  at  the  fundus  the  head  is 
freely  movable  upon  the  occipito-atloid  articulation. 

Back  and  limbs  will  be  found  in  the  same  way  as  with 
vertex  presentations.     In  the  incomplete  breech  presenta- 


362 


ABNORMAL   LABOUR 


tion  with  extended  legs  the  feet  He  close  to  the  head  and  may 
be  felt  there  ^er  abdomen  (Fig.  182)  ;  care  will  then  be 
necessary  to  avoid  the  error  of  concluding  that  the  breech 
lies  at  the  fundus  because  small  parts  are  found  near  it. 
The  heart-sounds  will  be  heard  at  about  the  level  of,  or  a  httle 
above  the  umbihcus — i.e.,  somewhat  higher  than  in  vertex 
presentations,  but  m  much  the  same  relative  position  as 
regards  the  middle  line  (Fig.  157).  In  the  first  breech 
position  the  heart-somids  are  unusually  loud,  owing  to  the 


Fig.  184. — Shape  of  tlie  Bag  of  Waters  in  a  Premature  Breecli  Laboui-. 
(Modified  from  Eibemont-Dessaignes  and  Lepage.) 

fact  that  the  back  of  the  left  shoulder  is  m  close  contact 
with  the  abdominal  wall,  a  little  to  the  left  of  the  umbihcus 
(Fig.  181). 

Vaginal  examination  early  m  labour  will  show  that  the 
presenting  part  hes  high  and  cannot  easily  be  defined  ;  the 
cervix  dilates  slowly  and  the  bag  of  waters  becomes  unusually 
elongated,  assuming  a  sausage  shape,  which  is  fanly  charac- 
teristic of  this  presentation  (Fig.  184).  This  alteration 
in  the  shape  of  the  bag  of  waters  results  from  the  small 
size  of  the  presenting  j)art  allowmg  an  unusually  large 
amount  of  hquor  amnii  to  descend  below  it,  thus  elongating 


BREECH   CASES 


363 


the  membranes.  Sometimes  the  presence  of  a  small  part 
(foot)  can  be  detected  in  the  bag  of  waters.  Details  of  the 
presenting  part  cannot  definitely  be  made  out  until  the 
cervix  is  one-haK  dilated  or  the  membranes  have  ruptured  ; 
but  at  this  stage  the  examining  finger  will  first  come  into 
contact  with  the  anterior  buttock — smooth,  soft,  and  round 
in  outline,  and  much  smaller  than  the  head.  Exploring 
further,  the  anus  will  be  found,  and  beyond  it  again  the 
coccyx  and  lower  sacral  ver- 
tebrae, the  latter  being  re- 
cognisable by  their  row  of 
small  spinous  processes.  On 
the  side  of  the  pelvis  oppo- 
site to  that  occupied  by  the 
sacrum  one  or  both  feet  may 
be  found  (Fig.  185),  and  the 
finger  may  be  passed  into  the 
cleft  of  the  groin  between  the 
flexed  thigh  and  the  ab- 
dominal wall.  The  male  ex- 
ternal genital  organs  may 
also  be  recognised  and  the 
sex  thus  determined.  The 
presence  of  meconium  on  the 
examining  finger  which  has 
been  passed  into  the  anus  is 
of  course  pathognomonic  of 
this  presentation.  The  local- 
isation of  the  sacrum  is  of 
considerable  importance,  for 
by  it  the  position  can  be  recognised.  In  the  first  and  fourth 
positions  it  lies  to  the  left,  and  either  in  front  or  behind 
respectively  ;  in  the  second  and  third  positions  it  lies  to 
the  right,  and  either  in  front  or  behind  respectively.  The 
diagnosis  of  position  in  breech  presentations  is  not  so  im- 
portant as  in  presentations  of  the  vertex  or  face. 

The  incomplete  breech  with  extended  legs  is  not  easily 
recognised  as  such  either  by  vaginal  or  abdominal  examina- 
tion when  the  presenting  part  is  still  in  the  pelvic  brim  ; 
when  the  breech  has  passed  into  the  pelvic  cavity,  the  fact 
that  the  feet  are  not  within  reach  of  the  fingers  may  indicate 


Fig.  185.- — Breech  Presentation  : 
First  Position. 
Gibemont-Dessaignes  and  Lepage.^ 

Patient  in  usual  obstetric  position. 


364 


abxor:\lil  labour 


this  variety.  The  incomplete  breech  with  extended  thighs 
(laiee  or  footlmg)  is  easily  recognised  on  account  of  the  small 
size  of  the  presenting  parts  ;  the  foot  may  be  mistaken  for 
the  hand  before  rupture  of  the  membranes,  but  afterwards 
the  foot  can  always  be  distinguished  by  the  heel,  the  firm 
round  knob  bemg  quite  unlike  any  part  of  the  hand. 

Mechanism. — The  diameter  of  engagement  is  in  all  cases 
the  bi-trochanteric  or  bis-iliac  (both  4  inches),  which  enters 
the  brim  in  one  or  other  obhque  diameter  (4|  inches).     It 


Fig.  186. — Birth  of  the  Hips  in  Breech  Presentation,  showing 
Lateral  Flexion  of  the  Spine.  The  position  is  second,  the 
shoulders  engaging  in  the  right  oblique  diameter. 


will  be  observed  that  the  positions  correspond,  as  regards 
the  direction  of  the  back  of  the  foetus,  with  those  of  the 
vertex  and  face. 

Durmg  the  process  of  labour  a  movement  of  internal 
rotation  occurs,  affecting  successively  the  breech,  the 
shoulders,  and  the  head.  As  the  breech  descends,  the  bi- 
trochanteric  diameter  passes  from  the  oblique  of  the  brim 
(left  in  the  first  position)  into  the  antero-posterior  of  the 
outlet,  the  anterior  hip  coming  romid  under  the  symphysis 
pubis.  The  breech  is  then  born  by  a  movement  of  descent 
with  lateral  flexion  of  the  spine  around  the  pubes  (Fig.  186). 


BREECH   CASES  365 

The  anterior  hip  is  first  disengaged  ;  the  posterior  distends 
the  perineum  and  follows  it.  At  this  stage  the  shoulders 
(bis-acromial  diameter,  4|  inches)  engage  in  the  same 
oblique  diameter  of  the  brim  (left  in  the  first  position)  as  the 
breech,  and  in  passing  through  the  cavity  internal  rotation 
occurs,  bringing  the  anterior  shoulder  under  the  symphysis 
pubis  ;  the  trunk  is  born  with  the  arms  folded  across  the 
chest.  While  the  hips  lie  in  the  antero-posterior  diameter 
of  the  outlet,  and  the  shoulders  lie  at  the  same  time  in  the 
oblique  diameter  of  the  brim,  a  slight  amount  of  rotation  of 
the  dorsal  spine  must  of  course  occur.  The  head  should 
enter  the  brim  fully  flexed,  while  the  shoulders  are  passing 
through  the  outlet  ;  the  sub-occipito-bregmatic  diameter 
will  then  correspond  with  the  right  obhque,  and  forward 
rotation  of  the  occiput  follows,  the  anterior  shoulder  turning 
to  the  right  side  of  the  mother  (first  position).  The  head 
now  lies  with  the  nape  of  the  neck  behind  the  pubes,  the 
forehead  in  the  sacral  hollow,  and  the  face  upon  the  pelvic 
floor  ;  it  becomes  disengaged  by  the  chin,  face,  and  forehead 
successively  passing  over  the  perineum,  thus  maintaining 
the  flexed  position  to  the  end.  Backward  rotation  of  the 
occiput  is  practically  unknown  in  breech  labour  except  when 
the  foetus  is  very  small,  or  as  the  result  of  extension  of  the 
head  from  some  kind  of  interference  or  from  want  of  pelvic 
space.  In  the  posterior  positions  of  the  breech  (third  and 
fourth),  the  mechanism  of  labour  differs  little  from  that  of 
the  anterior  positions  (first  and  second).  Owing  to  the 
apposition  of  the  vertebral  column  of  the  foetus  to  the 
maternal  spine,  the  attitude  of  flexion  is  more  difficult  to 
maintain,  and  the  occurrence  of  extension  of  the  after- 
coming  head  is  therefore  more  frequent.  Internal  rotation 
of  the  head  is  a  long  movement  (three-eighths  of  a  circle)  as 
the  head  enters  the  brim  with  the  occiput  posterior  ;  if, 
however,  flexion  is  complete,  little  difficulty  is  to  be  antici- 
pated from  the  greater  length  of  this  movement. 

Owing  to  their  greater  size,  the  delivery  of  the  shoulders 
is  more  difficult  than  that  of  the  breech  ;  the  delivery  of 
the  head  is  more  difficult  than  either,  not  because  of  the 
length  of  its  diameters,  but  because  it  is  less  compressible 
than  the  breech  or  the  shoulders,  and  because  there  is  no 
time  for  moulding  to  occur. 


366  ABNORMAL   LABOUR 

The  head  is  but  little  altered  by  breech  labour.  Of 
course  no  ca'put  forms  upon  it,  and  there  is  practically  no 
mouldmg.  The  general  shape  is  therefore  distinctly  more 
globular  than  after  a  vertex  presentation. 

Anomalies  in  the  Mechanism. — (1)  Premature  rupture  of 
the  membranes,  with  consequent  loss  of  the  dilating  effect  of 
the  bag  of  waters,  frequently  occurs.  (2)  Extension  of  the 
legs  may  occur,  either  before  labour  as  an  abnormal  attitude, 
or  during  labour  from  some  obstacle  to  the  descent  of  the 
complete  breech.  A  breech  labour  is  prolonged  and  difficult 
when  extension  of  the  legs  occurs.  This  may  be  explained 
by  the  conditions  present.  Thus  the  extended  legs  act  as 
splints  to  the  trunk,  tending  to  straighten  it  and  to  oppose 
the  natural  attitude  of  flexion.  Further,  the  lateral  flexion  of 
the  spine,  which  usually  occurs  during  delivery  of  the  trunk, 
is  also  prevented.  Agaui,  the  later  stages  of  labour  will  be 
impeded  by  the  fact  that  the  head  and  the  feet  enter  the 
brim  together.  (3)  One  or  both  arms  may  become  displaced 
(extended)  during  the  passage  of  the  trunk  through  the 
pelvis  ;  the  displaced  hmb  then  lies  either  at  the  side  of, 
behind,  or  in  front  of  the  head,  and  forms  an  insuperable 
obstacle  to  spontaneous  delivery.  (4)  Non-rotation  either 
of  the  shoulders  or  of  the  head  may  also  occur,  and  delivery 
in  the  oblique  diameter  of  the  outlet  will  then  be  very 
difficult.  (5)  Finally,  backward  rotation  of  the  occiput 
may  occur  spontaneously  with  a  very  small  foetus.  Dis- 
engagement is  then  possible  in  one  of  two  ways  :  if  the  head 
is  completely  flexed,  the  face,  forehead,  and  vertex  will  pass 
successively  under  the  symphysis  ;  if  extended,  the  chin 
becomes  fixed  against  the  pubes,  the  occiput  is  disengaged 
first,  and  is  followed  successively  by  the  vertex  and  face,  the 
chin  coming  last  of  all. 

Prognosis. — The  duration  of  labour  is  somewhat  longer 
in  breech  than  in  vertex  presentations,  especially  in  primi- 
parse  ;  this  involves  in  itself  a  shghtly  increased  risk  to  both 
mother  and  child.  Unless  artificial  aid  in  extraction  is 
required,  the  maternal  risks  are  not  otherwise  increased  ; 
interference  of  course  increases  the  risks  both  of  laceration 
and  of  sepsis. 

The  risks  to  the  child  are,  however,  decidedly  greater 
than  in  vertex  cases,  and  recent  statistics  estimate  the  foetal 


BREECH   CASES  367 

mortality  in  labour  at  1  in  9  (primiparse)  to  1  in  30  (multi- 
parse).  Older  statistics  might  be  quoted  in  which  the  foetal 
mortality  was  about  25  per  cent.  In  addition  many  infants 
born  alive  succumb  within  forty-eight  hours  to  injuries 
received  during  labour.  Certain  foetal  risks  are  almost 
unavoidable,  such  as  (a)  compression  of  the  cord  during 
delivery  of  the  head,  (6)  premature  attempts  at  respiration 
from  stimulation  of  the  respiratory  centre  before  the  head  is 
born.  In  addition  it  has  been  shown  by  Spencer,  that  serious 
injuries  to  the  abdominal  and  thoracic  viscera  from  com- 
pression of  the  trunk  may  often  be  found  on  post-mortem 
examination  of  infants  that  have  died  during  or  soon  after 
breech  delivery.  And  further,  from  traction  on  the  limbs 
and  shoulders,  rupture  of  muscular  fibres,  fracture  of  bones, 
and  injury  to  nerve  trunks  may  occur.  Such  accidents  as 
prolapse  of  the  cord  or  premature  rupture  of  the  membranes 
are  frequently  met  with,  and  further  increase  the  risks  to 
the  child. 

Management. — When  a  breech  presentation  is  discovered 
during  the  last  four  weeks  of  pregnancy,  or  very  early  in 
labour,  it  may  be  converted  into  a  vertex  by  external  version 
(p.  671)  ;  this  should  always  be  done  if  the  patient  is  a 
primigravida,  or  if  the  pelvis  is  small  and  of  the  generally 
contracted  type  (p.  395).  In  a  multipara  with  a  normal 
pelvis,  correction  of  the  presentation  is  not  of  such  great 
importance,  but  should  be  performed  in  the  interests  of  the 
child.  It  must  be  recollected  that  after  correction  the 
unfavourable  presentation  is  apt  to  recur,  and  repeated 
examination  should  accordingly  be  made.  Wearing  a  tight 
binder  is  of  some  assistance  in  maintaining  the  corrected 
position. 

During  the  first  stage  of  labour  especial  care  is  necessary 
to  preserve  the  bag  of  waters  ;  when  this  has  ruptured,  an 
examination  should  immediately  be  made  to  confirm  diag- 
nosis and  to  look  out  for  prolapse  of  the  cord.  Untimely 
interference,  such  as  extraction  of  the  breech  before  the 
cervix  is  fully  dilated,  will  lead  to  great  difficulty  in  extract- 
ing the  head.  It  is  therefore  of  special  importance  to  avoid 
interfering  too  soon.  Even  during  the  second  stage  nothing 
whatever  should  be  done,  when  labour  progresses  favourably, 
until  the  buttocks  have  been  completely  expelled  from  the 


368 


ABNORMAL  LABOUR 


vulva.  The  work  of  the  medical  attendant  then  begins,  and 
the  survival  of  the  child  will  often  depend  upon  his  knowledge 
of  what  is  required,  and  of  how  to  do  it.  The  legs  should  be 
gently  disengaged  by  seizing  the  feet  and  extending  first  one 


Fig.  187. — Breecli  Presentation,  showing  how  to  hold  the  Body 
of  the  Child.     (Eibenlont-Dessaignes  and  Lepage.) 

Note.— "[he  body  should  be  wrapped  up  to  protect  it  from  cold  air. 

leg  and  then  the  other  with  the  fingers  passed  into  the 
vagina.  The  exposed  parts  must  be  wrapped  up  in  a  warm 
towel  and  carefully  protected  during  the  remainder  of  the 
labour,  in  order  to  avoid  the  risk  that  cutaneous  stimulation 
by  cold  air  may  prematurely  excite  the  respiratory  centre. 
The  umbilical  cord  should  be  sought  for  and  a  loop  pulled 


BREECH  CASES 


369 


down  so  that  its  pulsation  may  be  watched  during  the 
remaining  stages.  Traction  on  the  legs  is  not  required  at 
this  period,  and  the  temptation  to  pull  must  be  steadily- 
resisted,  for  it  is  obvious  that  traction  will  tend  to  produce 
extension  of  the  spine,  and  this  again  will  induce  extension 
of  the  head,  because  the  vertebral  column  articulates  with 
the  head  nearer  the  occiput  than  the  sinciput.  But  the 
descent  of  the  trunk  may  be  aided  by  pressure  with  the  hand 


Fig.  188. — The  Mauriceau-Veit  Grip  in  delivering  the  After-coming 
of  the  Head.     First  Stage.     (Ribemont-Dessaignes  and  Lepage.) 

on  the  fundus  during  the  pains  ;  fundal  pressure  is  also 
useful  in  maintaining  the  flexed  attitude  of  the  arms  and 
head.  As  the  trunk  descends  it  will  be  observed  to  rotate 
as  the  shoulders  pass  into  the  antero-posterior  diameter  of 
the  outlet,  the  direction  of  rotation  being  from  right  to  left 
in  the  first  position.  If  the  normal  attitude  of  the  arms  has 
been  preserved,  the  elbows  will  then  appear  closely  pressed 
against  the  chest.  In  holding  the  child  at  this  stage,  the 
hand  should  grasp  the  pelvis,  not  the  waist  (Fig.  187),  lest 
E.M.  24 


370  abxor:nl\l  labour 

injury  should  be  done  to  the  abdominal  viscera.  When  the 
child  is  small  the  head  may  be  spontaneouslj^  disengaged  by 
a  voluntar}^  effort  of  the  mother  ;  more  often,  however, 
assistance  is  requned.  The  simplest  method  is  to  grasp  the 
legs  and  carry  the  trunk  of  the  child  forwards  parallel  with 
the  mother's  abdominal  wall,  at  the  same  time  makmg 
pressure  on  the  head  in  the  axis  of  the  pelvic  brim  (down- 
wards and  backwards)  with  the  hand  on  the  fundus.  Fre- 
quently, however,  this  simple  manoeuvre  does  not  suffice, 
and  as  the  foetal  circulation  is  at  this  stage  necessarily  inter- 
fered with  by  compression  of  the  cord  or  the  placenta, 
prompt  measures  should  be  taken  to  deliver  the  head.  The 
best  method  to  adopt  is  that  of  Mauriceau  or  Veit — the 
credit  of  it  is  claimed  for  both  (Figs.  188  and  189).  The 
trunk  of  the  child  is  taken  upon  the  right  forearm,  mth  the 
legs  astride,  the  index  finger  having  been  passed  up  to  the 
face  and  inserted  into  the  mouth  in  order  to  make  traction 
upon  the  lower  jaw.  The  left  hand  is  placed  upon  the 
shoulders,  the  neck  lying  between  the  index  and  middle 
fingers.  Traction  is  then  made  with  both  hands  m  the 
dnection  of  the  axis  of  that  part  of  the  pelvic  cavity  in 
which  the  head  is  lying.  Flexion  is  maintained  or  extension 
corrected  by  the  finger  m  the  mouth,  and  descent  may  be 
aided  by  an  assistant  making  pressure  on  the  fundus. 
When  the  head  reaches  the  outlet,  the  direction  of  traction 
must  of  course  be  changed  (Fig.  189),  and  is  now  applied 
chiefly  to  the  shoulders,  the  lower  hand  merelj^  mamtaining 
the  flexion  of  head. 

The  grip  of  the  head  thus  obtamed  is  verj^  effective  ;  it  is 
m  reality  a  combmation  of  two  grips  which  were  formerly 
practised  separately,  the  anterior  grip  or  jaw-traction  being 
named  after  SmeUie  (Smellie  grip),  and  the  posterior  grip 
after  the  great  midwifery  school  of  Prague  (Prague  grip). 
Time  is,  however,  saved  hj  emj)loying  them  in  combination, 
and  success  at  this  stage  depends  mainly  uj)on  the  prompt 
application  of  effective  methods.  In  the  figures,  the 
manoeuvre  is  shown  with  the  patient  m  the  dorsal  position  ; 
it  can  be  equallj;^  well  performed  with  the  patient  Ijang  upon 
the  left  side,  when  the  hands  may  be  reversed. 

If  the  head  cannot  be  delivered  in  this  way,  the  forceps 
should    at    once    be  applied.      The    child    cannot    survive 


BREECH  CASES 


37] 


compression  of  the  cord  for  more  than  five  to  ten  minutes, 
therefore  forceps  should  be  always  got  ready  for  immediate 
use  before  commencing  the  delivery  of  the  after-coming  head. 

Difficulties  may  arise  during  a  breech  labour  at  three 
different  stages  :  (1)  in  the  delivery  of  the  buttocks,  (2)  in 
the  delivery  of  the  arms,  (3)  in  the  delivery  of  the  head. 

(1)  The  birth  of  the  buttocks  may  be  delayed   (a)   by 


Fig.  189. — The  Mauriceau-Yeit  Grip.     Second  Stage. 
(Ribemont-Dessaignes  and  Lepage.) 

uterine  inertia,  (6)  by  the  large  size  of  the  foetus  or  the 
insufficient  size  of  the  pelvis,  (c)  by  extension  of  the  legs. 

In  the  case  of  a  primipara  a  further  important  cause  of 
delay  is  always  present  in  the  narrow  and  relatively  rigid 
vaginal  canal.  The  breech  forms  an  imperfect  dilator,  and 
the  risk  of  extension  of  the  arms  is  increased  by  the  un- 
yielding vaginal  walls.  Dilatation  of  the  vagina  may  there- 
fore be  assisted  by  the  use  of  de  Ribes's  bag  during  the  second 
stage.  It  may  be  passed  into  the  vagina  as  far  up  as  possible, 
then  inflated,  and  either  left  to  be  expelled  by  the  natural 

24—2 


372 


abxor:\ial  laboue 


forces,  or  by  making  traction  on  the  bag  it  may  be  gradually 
drawn  through  the  vulva  so  as  to  dilate  it  in  advance  of  the 
breech.  This  method  also  gxeatly  facihtates  subsequent 
manipulations,  Trhich  may  be  required  to  bring  down  the 
arms  or  the  head. 

The  safest  and  surest  mode  of  dealing  with  difficulty  ia 
dehvering  the  buttocks,  no  matter  how  it  may  be  caused, 
is  to  bring  down  a  leg  :  it  is  the  best  method  whether 
the  buttocks  lie  at  the  jDelvic  brim  or  in  the  cavity.     An 


Ftg.  190. — Breeeh  Presentation.      Biinging  down  a  Leg. 
(Ribemont-Dessaignes  and  Lepage.) 

ansesthetic  is  reqimed,  and  the  entne  hand  is  then  passed  into 
the  vagina,  strict  antiseptic  precautions  being  observed  and 
rubber  gloves  worn.  The  anterior  limb  should  be  brought 
down  ui  preference  to  the  posterior.  The  fingers  follow  the 
anterior  thigh  up  to  the  back  and  inner  side  of  the  knee,  and 
pressme  is  then  made  upon  the  limb  at  this  point  so  as  to 
abduct  it  ;  this  will  flex  the  leg  and  bring  the  foot  down 
within  reach,  so  that  it  can  be  seized  and  drawn  down 
into  the  vagina  (Fig.  190).  The  same  precautions  must  be 
observed  in  this  manoeuvre  as  in  the  operation  of  internal 


BREECH  CASES 


373 


version  (see  jd.  681).  A  looj)  of  the  cord  may  come  down 
with  the  leg  ;  it  must  be  carefully  replaced,  well  above  the 
level  of  the  buttocks.  The  expulsion  of  the  child  should 
now^  be  left  to  the  natural  efforts,  unless,  from  interference 
with  the  foetal  circulation,  rapid  delivery  is  indicated.  In 
cases  where  this  manoeuvre  is  practised  for  uterine  inertia, 
good  pains  will  usually  follow  from  the  stimulation  set  up 
by  the  manipulations. 

It  occasional!}^  happens  that  rapid  extraction  of  a  breech 
presentation  becomes  necessary  from  foetal  distress  or  from 
maternal  comjDlications.  Both  feet  should  then  be  brought 
down,  and  deUvery  effected  by  combined  traction  and  supra- 
pubic pressure.  This  cannot  be  attempted  until  the  cervix 
is  fully  dilated. 

When  the  breech  is  arrested  in  the  pelvic  cavity,  difficulty 


Fig.  191.— Breech  Hook. 


may  be  experienced  in  passing  the  hand  beside  the  breech 
into  the  uterus,  where  the  legs,  if  extended,  will  be  found. 
Und-er  deep  anaesthesia  it  is,  how^ever,  usually  practicable  to 
push  the  buttocks  upwards  to  the  level  of  the  brim,  when  the 
hand  can  be  slipped  past  them  more  readily.  As  an  alter- 
native the  method  of  applying  traction  dnectly  to  the 
buttocks  may  be  carried  out  either  by  the  fingers  or  by  the 
breech  hook.  The  most  effectual  method  of  traction  is  by 
means  of  the  Breech  Hook  (Fig.  191).  This  is  a  blunt-pointed 
metal  hook,  the  width  of  which  should  be  at  least  2\  inches. 
It  is  appUed  by  passing  it  over  the  lateral  aspect  of  the 
anterior  buttock  until  the  point  Ues  above  the  level  of  the 
fold  of  the  groin  ;  the  instrument  is  then  rotated  through  a 
right  angle  so  as  to  bring  the  hook  across  the  child's 
abdomen  ;  a  finger  is  then  passed  between  the  thighs,  and 


374  ABNORMAL   LABOUR 

the  point  of  the  hook  is  carefully  guided  into  position  on  the 
inner  aspect  of  the  anterior  thigh.  Traction  can  then  be 
applied  in  the  fold  of  the  groin,  and  if  care  and  gentleness  are 
exercised  there  is  little  fear  of  injury  occurring.  Fracture  of 
the  femur  or  pelvis,  or  dislocation  of  the  hip  may,  however, 
occur  if  great  force  is  applied  ;  therefore  every  effort  should 
always  be  made  to  effect  delivery  by  bringing  down  a  leg, 
unless  the  child  is  dead,  when  there  is  no  objection  whatever 
to  the  use  of  the  breech  hook.  When  the  arrest  of  the 
breech  in  the  pelvic  cavity  is  due  solely  to  inefficiency  of  the 
uterine  pains,  traction  with  the  fingers  may  succeed  in 
delivering  it.  The  index  finger  is  passed  over  the  dorsal 
aspect  and  then  hooked  into  the  groin  ;  whichever  groin 
can  be  most  easily  reached  can  be  made  use  of.  Only  one 
finger  should  be  used  and  care  taken  to  avoid  direct  pressure 
on  the  femur.  The  introduction  of  the  finger  will  often  be 
found  to  stimulate  greatly  the  uterine  contractions.  What- 
ever method  is  employed  traction  is  to  be  made  only  during 
the  pains,  and  should  be  aided  by  pressure  from  above. 

Traction  may  also  be  applied  to  the  breech  with  the 
obstetric  forceps,  and  this  method  is  recommended  by  some 
authorities.  This  instrument  is,  however,  ill-adapted  for 
application  to  the  breech,  and  if  the  points  of  the  instrument 
are  allowed  to  pass  above  the  iliac  crests,  injury  may  be  done 
to  the  abdominal  viscera.  The  use  of  forceps  is  not  to  be 
recommended  as  a  routine  procedure,  but  may  be  tried  after 
an  attempt  to  bring  down  a  leg  has  proved  unsuccessful,  as 
an  alternative  to  the  use  of  the  blunt  hook. 

(2)  Difficulty  in  the  delivery  of  the  arms  results  from 
their  becoming  displaced  ;  this  is  usually  due  to  traction 
having  been  applied  in  delivering  the  buttocks,  but  it  may 
also  be  due  to  disproportion  between  the  size  of  the  foetus 
and  the  pelvis.  The  displacement  is  usually  lateral  (exten- 
sion) as  shown  in  Fig.  192.  The  shoulders  will  then  probably 
lie  in  the  oblique  diameter  of  the  brim  ;  therefore  one  arm 
will  be  anterior,  the  other  posterior.  On  account  of  the 
curvature  of  the  sacrum,  it  will  be  easier  to  reach  the  arms 
from  behind  than  in  front.  The  trunk  should  be  first 
rotated  into  the  transverse  diameter,  where  there  is  more 
room  for  the  necessary  manipulations.  The  whole  hand 
must  then  be  passed  along  the  trunk  of  the  child  into  the 


BREECH  CASES 


375 


vagina,  and  the  thumb  and  first  two  fingers  carried  along  the 
humerus  until  the  elbow  is  reached  ;  the  forearm  can  then 
be  flexed  over  the  face  and  chest,  and  the  limb  thus  delivered. 
An  anaesthetic  is  usually  required  for  this  manoeuvre.  There 
is  no  risk  of  injuring  the  limb  if  traction  is  applied  only  to 
the  elbow  or  the  forearm.  Occasionally  one  arm  becomes 
displaced  laterally   (extended),   the   other  lies   behind   the 


Retracted 
utents 


Fig.  192. — Lateral  Displacement  of  tlie  Anterior  Arm;  the  Posterior 
Arm  lias  been  already  brought  down. 


occiput.  The  extended  arm  should  first  be  delivered  ;  next 
the  pelvis  should  be  seized  and  the  trunk  rotated  towards 
the  same  side  as  the  limb  which  lies  behind  the  occiput  ; 
this  will  bring  the  posterior  arm  into  a  lateral  position,  where 
it  can  be  reached  and  delivered  in  the  usual  manner. 

(3)  Difficulty  in  delivering  the  head  results  either  from 
its  large  size,  from  extension,  from  backward  rotation,  or 
from  contraction  of  the  pelvis.  The  mechanical  disadvan- 
tage of  extension  of  the  after-coming  head  is  indicated  in 


376 


ABNOR^IAL  LABOUR 


Fig.  193.  "WTien  flexed,  the  head  forms  a  wedge  the  apex 
of  which  is  directed  downwards  ;  when  extended,  the  base 
of  the  wedge  is  directed  downwards,  and  descent  is  therefore 
much  more  difficult.  In  addition,  the  occipito-mental  dia- 
meter (4^  inches)  engages  instead  of  the  sub-occipito-frontal 
(4  inches).  If  the  extended  head  is  delayed  at  the  brim,  it 
should  be  first  rotated  into  the  transverse  diameter,  and  then 
flexed  by  traction  on  the  lower  jaw  with  the  finger  j)assed 


Fig.  193.— The  Aftercomiii":  Head.     a.  Flexed,     h.  Extended. 


into  the  mouth.  It  may  then  be  rotated  and  extracted  by 
the  Mauriceau-Veit  grip,  or,  if  this  fails,  by  forceps.  When 
the  head  is  already  in  the  cavity  forceps  may  be  at  once 
ai)|)hed.  ^ATienever  the  child  is  dead  jDerforation  should  be 
jDerformed  without  hesitation  to  secure  easy  deliver3\  If 
backward  rotation  has  occurred,  an  attempt  should  be  made 
to  rotate  the  head  and  trmxk  so  as  to  brmg  the  occiput  for- 
wards ;  should  this  fail,  perforation  will  be  required  unless 
the  head  is  very  small. 


SHOULDER  CASES 


377 


Transverse  or  Shoulder  Presentations 

These  presentations  uiclude  all  cases  in  which  the  long 
axis  of  the  foetus  lies  more  or  less  directly  across  the  long  axis 
of  the  uterus — i.e.  all  varieties  of  the  transverse  or  oblique 
lie.  Some  part  of  the  trunk  of  the  foetus  presents — almost 
invariably  by  its  lateral  aspect.  The  shoulder  (acromion 
process)  in  most  instances  forms  the  denominator  of  the 
presentation  ;  but  sometimes  the  arm  becomes  prolapsed  and 
descends  first  into  the  vagina,  while  at  other  times  the  lateral 
aspect  of  the  abdomen, 
or  even  the  back,  forms 
the  actual  presenting 
part. 

It  is  usual  to  de- 
scribe only  two  positions 
of  the  shoulder  presen- 
tation, dor  so-anterior 
and  dorso-posterior ;  the 
former  is  much  com- 
moner than  the  latter, 
because  the  foetus 
accommodates  itself 
better  in  that  position  to 
the  forward  curvature 
of  the  lower  dorsal  and 
lumbar  vertebrae.  In 
the  former  the  normal 

fcetal  attitude  of  flexion  is  fairly  well  preserved  (Fig.  194)  ; 
in  the  latter  the  spine  becomes  extended  and  displacement 
of  the  limbs  is  frequently  met  with  (Fig.  195)  ;  premature 
rupture  of  the  membranes  and  prolapse  of  the  cord  are 
common  in  both  positions.  The  head  usually  occupies  the 
iliac  fossa,  the  breech  lying  upon  the  opposite  side  at  a 
somewhat  higher  level,  so  that  the  long  axis  of  the  foetus 
is,  strictly  speaking,  not  .transverse  but  oblique.  More 
rarely  the  breech  occupies  the  iliac  fossa,  while  the  head  lies 
at  the  higher  level. 

Occurrence. — Shoulder  presentations  occur  in  about 
1  in  200  (0'5  per  cent.)  labours.  When  premature  labours 
are  excluded  the  rate  of  frequency  is  much  reduced.     They 


Fig.  194. — Shoulder  Presentation :  Dorso- 
anterior  Position.  (Eibemont-Des- 
saignes  and  Lepage.) 

The  general  attitude  of  flexion  is  preserved. 


378 


ABNORMAL   LABOUR 


are  five  or  six  times  more  frequent  in  multiparse  than  in 
primigraviclse. 

Causes. — All  conditions  which  prevent  the  ready  descent 
of  the  foetal  head  into  the  pelvic  brim  may  occasion  a  shoulder 
presentation — e.g.  pelvic  contraction,  hj^dramnios,  placenta 
prsevia,  twins,  extreme  uterme  obliquitj^,  laxity  of  the 
uterine  and  abdominal  muscles,  premature  or  dead  foetus,  &c. 
It  will  be  recollected  that  the  same  conditions  may  cause 

other  forms  of  abnormal 
presentation.  The  rela- 
tive frequency  of  this 
presentation  in  multiparse 
is  probably  to  be  ex- 
plamed  by  permanent 
weakening  of  the  abdo- 
minal muscles,  permitting 
forward  or  extreme  lateral 
displacement  of  the  uterus 
to  occur. 

Diagnosis. — This  pre- 
sentation can  easily  be 
recognised  by  abdominal 
palpation,  before  labour 
has  commenced,  or  early 
in  the  first  stage  when  the 
membranes  are  intact. 
The  uterus  is  not  pyra- 
midal in  shape,  but  ir- 
regular, the  long  axis 
lying  more  or  less  com- 
pletely across  the  ab- 
domen ;  as  the  present - 
mg  part  cannot  descend  uit'o  the  brim  the  level  of  the  fundus 
is  unaltered.  Systematic  palpation  will  show  that  the 
head  occupies  one  or  other  iliac  fossa,  and  usually  that  the 
back  is  anterior  ;  the  breech  mil  then  be  found  on  the  oppo- 
site side  and  at  a  higher  level  than  the  head  ;  occasionally 
however,  the  breech  will  be  found  in  the  iliac  fossa. 
Auscultation  of  the  foetal  heart  does  not  assist  the  diagnosis 
of  this  presentation. 

In  examining  women  who  are  several  weeks  short  of 


Fig.  195.— Shoulder  Piesentat'on  : 
Dorso -posterior  Position.  (Ptibe- 
mont-lJessaignes  and  Lepage.) 

The  spine  is  extendeil  and  the  limbs  are  displaced. 


SHOULDER  CASES 


379 


full  time,  transverse  presentations  are  comparatively 
frequently  met  with  ;  probably  a  certain  proportion  of 
them  become  corrected  spontaneously  before  labour.  The 
lie  in  such  cases  is  often  quite  irregular,  the  whole  body 
of  the  foetus  lying  well  above  the  pelvic  brim. 

Nothing  can  be  made  out  on  vaginal  examination  before 
labour,  except  that  the  presenting  part  lies  high  up  and  is  soft 
to  the  touch.  During  the  first  stage  a  large  and  elongated 
bag  of  waters  will  form,  in  which  a  small  part — the  arm — 
may  be  felt  ;  if  the  membranes  have  ruptured,  the  arm 
may  become  prolapsed  early  in 
labour. 

Late  in  labour,  when  the 
liquor  amnii  has  escaped  and  the 
uterus  has  become  moulded 
around  the  body  of  the  fcEtus, 
detailed  abdominal  palpation  is 
very  difficult,  and  the  position 
of  the  different  parts  of  the  foetus 
cannot  in  this  way  be  made  out. 
Diagnosis  must  then  be  made  by 
vaginal  examination.  A  prolapsed 
arm  will,  of  course,  settle  the 
presentation  at  once,  and  the 
position  of  the  head  and  back 
can  be  deduced  from  the  relation 
of  the  hand  when  supinated :  the 
thumb  pointing  to  the  head,  the 
palm  corresponding  to  the  ventral  aspect.  When  prolapse 
of  the  arm  does  not  occur,  diagnosis  will  be  more  difficult. 
In  almost  all  cases,  however,  the  ribs  with  their  intercostal 
spaces,  or  the  vertebral  spines,  can  be  recognised  with  the 
finger,  which  usually  reaches  the  former  along  the  posterior 
axillary  border  (Fig.  196)  ;  these  parts  can  hardly  be  mis- 
taken for  anything  else.  The  angle  of  the  scapula,  freely 
movable  and  projecting  from  the  surface  of  the  back,  may 
also  be  recognised,  and  is  useful  as  indicating  the  position 
of  the  back.  The  acromion  process  and  the  curved  clavicle 
may  also  sometimes  be  identified.  By  passing  the  exploring 
finger  towards  the  right  or  left  side  of  the  mother,  the  finger 
can  be  passed  into  the  pit  formed  by  the  apex  of  the  axilla  ; 


Fig.  196.— Shoulder  Presen- 
tation :  Dorso-posterior 
Position.  (Eibemont- 
Dessaignes  and  Lepage.) 

Patient  in  usual  obstetric  position. 


380 


ABNORMAL   LABOUR 


the  head;  of  course,  hes  upon  the  same  side  of  the  pelvis  as 
the  axillary  pit. 

Mechanism. — Xatural  delivery  in  a  shoulder  presentation 
is  impossible  when  the  foetus  is  full  sized  ;  under  exceptional 
circumstances,  however,  it  may  take  place  in  one  of  the 
following  three  ways  : 

A.  Spontaneous  version  may  occur — i.e.  the  presentation 
may  spontaneously  become  transformed  into  a  breech  or  a 

vertex.  This  occurrence  has  been 
observed  earty  in  labour,  before  the 
membranes  have  ruptured  or  the 
presenting  part  has  become  engaged. 
It  was  first  described  by  an  English 
obstetrician  of  the  eighteenth  cen- 
tury named  Denman.  The  term 
'  spontaneous  version  '  is  usually 
applied  only  to  the  transformation 
of  a  shoulder  into  a  breech  presen- 
tation ;  when  transformed  into  a 
vertex  the  process  is  called  sponta- 
neous rectification.  This  is  an  un- 
necessary distinction,  since  version 
may  be  either  cephalic  or  peh^ic 
(see  p.  671).  No  precise  observa- 
tions have  been  made  upon  the 
mechanism  of  spontaneous  version  ; 
its  occurrence  is  no  doubt  very 
rare. 

B.  Spontaneous  evolution  may 
occur  when  the  foetus  is  smaU  or 
macerated,  the  pelvis  large,  and  the 
uterine  contractions  powerful.  This 
process,  first  described  by  a  Dublin 
obstetrician,  Douglas  (beginning  of  nineteenth  century),  has 
been  studied  by  Ribemont-Dessaignes  and  others  who  were 
able  to  obtam  photographs  of  the  different  stages  of  dehvery. 
The  attitude  assumed  by  the  foetus  is  shown  in  Fig.  197  ; 
extreme  flexion  of  the  head  and  the  cervical  spme  occurs, 
causing  severe  comjDression  of  the  thoracic  and  abdominal 
viscera  ;  and  even  if  the  foetus  is  ahve  at  the  onset  of  labour, 
death  invariably  occurs  during  delivery.     Prolapse  of  the 


Fig.  197.— Attitude  of  the 
Fcjetus  in  SiDoutaueoiis 
Evolution.  From  Na- 
ture. (Eibemout-Des- 
saignes  and  Lepage.) 


SHOULDER  CASES 


381 


posterior  arm  first  takes  place,  and  the  head  and  trunk  then 
become  compressed  by  the  uterine  contractions  into  the 
smallest  possible  bulk.  After  the  expulsion  of  the  prolapsed 
arm  and  shoulder  (Fig.  198)  the  anterior  shoulder  appears 
under  the  symphysis,  and  the  back  follows,  being  expelled  in 
the  oblique  diameter  of  the  outlet.  As  the  disengagement 
of  the  trunk  proceeds,  a  movement  of  rotation  occurs, 
carrying  it  into  the 
transverse  diameter,  the 
head  being  on  one  side, 
the  breech  on  the  other 
(Fig.  199).  Forward 
rotation  of  the  shoulders 
next  takes  place,  bring- 
ing the  neck  under  the 
symphysis  pubis,  and  the 
legs  become  disengaged 
in  the  antero-posterior 
diameter  (Fig.  200). 
Labour  terminates  like 
a  breech  case  with  the 
delivery  of  the  after- 
coming  head.  The  foe- 
tus represented  in  these 
figures  (photographed 
from  nature)  weighed 
five  and  a  half  pounds. 

In  Fig.  201  is  shown 
the  process  of  evolution 
arrested  at  an  early 
stage  by  the  death  of 
the  mother.  The  atti- 
tude   of    the    foetus     is 

similar  to  that  shown  in  Fig.  197,  and  the  greater  part  of  the 
trunk  has  been  driven  into  the  vagina.  This  constitutes 
what  is  clinically  known  as  an  '  impacted  shoulder.'  The 
special  risks  which  attend  all  methods  of  delivery  in  im- 
paction of  the  shoulder  are  indicated  by  the  condition  of 
the  uterus.  It  will  be  seen  that  the  lower  uterine  segment 
is  thinned,  the  bladder  greatly  elevated,  and  the  upper  part 
of  the  uterus  much  retracted. 


Fig.  198. — Spontaneous  Evolution, 
Photographed  from  Nature.  First 
Stage  of  Delivery,  showing  Prolapse 
of  Posterior  Arm..  (Eibemont- 
Dessaignes  and  Lepage.) 


382 


ABNORMAL   LABOUR 


C.  Spontaneous  expulsion  is  also  described  as  a  possible 
termination  in  the  case  of  a  macerated  foetus.  From  the 
accounts  of  observers  who  have  watched  the  process,  it  is 
clear  that  it  does  not  differ  in  any  important  respect  from 
spontaneous  evolution,  and  scarcely  deserves  to  be  recog- 
nised as  distinct  from  the  latter.  The  trunk  of  the  macerated 
foetus  is  very  compressible,  and  may  therefore  be  more 
completely  bent  upon  itself,  allowing  the  head  and  breech 

to  be  disengaged  together 
(Fig.  202). 

It  must  be  clearly 
understood  that  these 
natural  terminations  of 
shoulder  presentations  are 
exceptional  occurrences, 
and  cannot  under  any 
circumstances  be  awaited. 
This  presentation  must 
invariably  be  dealt  with 
by  immediate  interfer- 
ence in  the  manner  in- 
dicated below.  If  allowed 
to  continue,  the  case  will 
in  all  probability  become 
one  of  obstructed  labour  ; 
over  -  distension  of  the 
lower  uterine  segment 
will  ensue  (see  p.  463), 
the  child  will  die  of  com- 
pression, and  the  mother, 
unless  rescued  by  opera- 
tive measures,  will  die 
undelivered,  either  of  exhaustion  or  of  rupture  of  the  uterus. 
Management. — Since  it  is  impossible,  unier  ordinary 
conditions,  for  natural  delivery  to  take  place  in  shoulder 
presentations,  the  treatment  consists  in  converting  the 
presentation  into  a  vertex  or  a  breech  by  one  of  the  methods 
of  version,  ^^rovided  that  labour  has  not  advanced  too  far  to 
permit  of  this  being  done.  These  methods  will  be  described 
in  connection  with  the  obstetric  operations.  If  abdominal 
examination  is   regularly  practised  during  the  latter  weeks 


Fig.  199. — Spontaneous  Evolution. 
Second  Stage,  showing  Delivery 
of  Back  ill  the  Transverse  Dia- 
meter. (Eibemont-Dessaignc  s  and 
Lepage.) 


SHOULDER  CASES 


383 


of  pregnancy,  shoulder  presentations  may  be  discovered 
before  the  onset  of  labour,  and  at  this  time  they  can  be 
corrected  by  external  version  with  ease  and  with  perfect 
safety  both  to  the  mother  and  the  foetus.  If  the  pelvis  is 
of  normal  size,  cephalic  version  should  be  practised.  The 
mal-presentation  is,  however,  apt  to  recur,  as  will  be  readily 
understood  if  its  causes  are  borne  in  mind.  After  correction 
of  a  shoulder  presentation  in  pregnancy  the  patient  should 
accordingly  be  examined  every  few  days  until  labour  begins. 
When  the  diagnosis  is 
made  early  in  labour  and 
the  membranes  are  intact, 
the  mal-presentation  can 
also,  as  a  rule,  be  corrected 
by  external  version.  At 
this  stage  it  is  better  to 
perform  external  podalic 
version,  and  then  rupture 
the  membranes  and  bring 
down  a  foot  into  the 
vagina,  so  as  permanently 
to  correct  the  mal-pre- 
sentation. This  can  be 
carried  out  without  diffi- 
culty if  the  cervix  is  large 
enough  to  admit  two  fin- 
gers under  anaesthesia . 

If  the  membranes  have 
already  ruptured  and  an 
arm  is  prolapsed,  external 
version  is  impossible.     In 

such  cases  a  loop  of  the  cord  also  may  become  prolapsed,  a 
complication  which  adds  greatly  to  the  foetal  risks.  These 
complications  may  be  dealt  with  as  follows  :  ( 1 )  If  the  cervix 
is  one-fourth  dilated  (two  fingers),  the  patient  should  be 
anaesthetised,  the  prolapsed  parts  carefully  returned  into 
the  uterus,  and  a  de  Ribes'  bag  then  introduced  into  the 
cervix.  This  will  prevent  recurrence  of  the  prolapse,  and 
at  the  same  time  dilate  the  cervix  and  prevent  further  escape 
of  liquor  amnii.  (2)  If  the  cervix  is  one-half  dilated  the 
hand  may  be  passed  into  the  uterus,  and  the  child  turned  by 


Fig.  200. — Spontaneous  Evolution. 
Third  Stage,  showing  Forward 
Eotatioti  of  Shoulders  and 
Delivery  of  Legs.  (Eibemont- 
Dessaignes  and  Lepage.) 


384 


ABNORMAL  LABOUR 


Fig.  201. — Impacted  Shoulder  Presentation  illustrating  a  stage  of 
Sponta:neous  Evokxtion.  Section  from  a  woman  who  died  in 
labour.  The  lower  uterine  segment  is  greatly  thinned,  and  the 
bladder  lies  completely  above  the  pubes.     (Barbour.) 

briiigiiig  down  a  leg  (internal  version),  the  cord  at  the  same 
time  being  returned  mto  the  uterus,  where  it  will  be  safe 
from  compression.     Delivery  may  then  be  left  to  nature. 


SHOULDER  CASES 


385 


(3).  Sometimes  shoulder  presentations  are  not  seen  until 
labour  is  advanced,  the  liquor  amnii  has  all  drained  away, 
and  the  uterus  is  retracted  over  the  body  of  the  fcetus 
(Fig.  201).  As  will  be  seen  in  a  later  section,  this  condition, 
if  allowed  to  continue,  is  attended  by  a  very  grave  maternal 
risk,  viz.,  rupture  of  the  uterus.  Version  under  these  con- 
ditions is,  generally 
speaking,  impractic- 
able, and  any  attempt 
to  effect  it,  unless  con- 
ducted with  great  care 
and  skill,  is  liable  to 
precipitate  a  rupture. 
Version  therefore  is  not 
to  be  recommended, 
(a)  unless  sufficient 
liquor  amnii  remains 
in  the  uterus  to  allow 
some  degree  of  mo- 
bility to  the  foetal 
parts  ;  (6)  unless  the 
uterus  becomes  well 
relaxed  between  the 
pains,  showing  that 
there  is  no  tonic  con- 
traction (see  p.  449)  ; 
(c)  unless  there  are  no 
signs  of  over-distension 
of  the  lower  uterine  seg- 
ment, such  as  undue 
prominence,  and  un- 
duly high  level  of  the 
retraction      ring      (see 

p.  463).  When  the  conditions  are  such  as  to  negative  version 
the  foetus  is  practically  always  dead,  and  the  method  of 
delivery  may  accordingly  be  selected  with  reference  solely 
to  the  interests  of  the  mother.  The  usual  method  employed 
is  decapitation,  followed  by  separate  delivery  of  the  trunk 
and  the  head.  In  all  cases,  when  the  conditions  present 
are  unfavourable  for  version,  and  the  foetus  is  dead,  de- 
capitation should  be  preferred. 

E.M. 


Fig.  202. — Transverse  Presentation. 
Delivery  by  Spontaneous  Expulsion. 
(Kleinwachter.) 


25 


386 


ABNORIMAL   LABOUR 


Twin  Labour 

The  diagnosis  of  twin  pregnancy  has  been  considered  on 
p.  101. 

Presentation. — The  two  foetuses  are  almost  invariably 
placed  side  by  side  m  the  uterus,  the  lie  of  each  bemg  longi- 
tudinal ;   more  rarely  one  is  placed  entirely  above  the  other. 


Fig.  203. — Twin  Labour  ;  both  Foetuses  presenting  by  the  Vertex. 


The  commonest  presentations  are  the  following,  the  propor- 
tions being  those  compiled  by  Leonhard  : 

First  child  vertex,  Second  child  vertex  . 
First  ,,  vertex,  Second  „  breech. 
First  ,,  breech,  Second  ,,  vertex. 
First  ,,  breech,  Second  ,,  breech. 
First      ,,      vertex  or  Ijreech,  Second  child  shoulder 

97-1% 

The  remainder  are  made  up  of  various  combinations,  the 


•     38-5% 

.     21-1% 

.     14-3% 

.     10-7% 

.     12-5% 

TWIN  LABOUR 


387 


rarest  of  all  being  that  in  which  both  presentations  are 
transverse. 

The  diagnosis  of  twins  is  often  easier  at  term  or  during 
labour  than  at  earlier  periods  of  pregnancy.  If  the  foetuses 
are  placed  as  in  Fig.  204  it  will  be  comparatively  easy  to 
determine  the  presence  of  two  heads,  one  at  the  brim  and 
one  at  the  fundus.  If,  however,  the  twins  are  placed  one 
in  front  of  the  other  the  presence  of  the  posterior  (Fig.  203) 
may  escape  the  most  careful  observation.  When  the  cervix 
is  dilated  two  bags  of  mem- 
branes may  sometimes  be 
felt. 

General  Course  of  Labour. 
— With  twins,  labour  fre- 
quently comes  on  prema- 
turely, and  shows  an  increased 
liability  to  the  occurrence  of 
certain  complications,  such 
as  (a)  hydramnios  (usually 
affecting  one  sac  only), 
(&)  premature  rupture  of  the 
membranes,  (c)  prolapse  of  a 
loop  of  the  cord  or  a  limb, 
(d)  uterine  inertia,  (e)  complex 
presentations.  As  a  conse- 
quence, twin  labour  is  usually 
somewhat  prolonged  ;  this  is 
due  partly  to  weakness  of  the 
over-distended  uterine  wall, 
which  results  in  primary 
inertia  (see  p.  443),  and  partly 
to  the  fact  that  the  stage  of  expulsion  is  duplicated.  These 
disadvantages  are  to  some  extent  counterbalanced  by  the 
small  size  of  twin  foetuses.  In  other  respects  the  course  of 
labour  depends  entirely  upon  the  relation  of  the  foetuses  to 
one  another.  When  the  pelvis  is  full-sized  or  unusually 
large,  the  first  foetus,  being  small,  does  not  fill  it,  and  the 
presenting  part  of  the  second  may  enter  the  brim  simul- 
taneously with  the  first  ;  the  passage  of  both  will  thus 
become  obstructed  ;  this  is  known  as  twin  locking.  It  must 
be  recollected  that  this  complication  is  extremely  uncommoUj 

25—2 


Pig.  204. — Twin  Labour  :  First 
Foetus  presents  by  the  Vertex, 
Second  by  the  Breech  (in- 
complete). 


388  ABNORMAL   LABOUR 

and,  according  to  Von  Braun,  occurred  only  once  in  90,000 
deliveries  in  Vienna  ;  as  twin  labour  occurs  in  something 
like  1  in  80  to  90  cases,  it  follows  that  twin  locking  occurred, 
in  Von  Braun's  series,  in  only  0"1  'per  cent,  of  twin  labours. 
The  following  are  the  prmcipal  varieties  :  (1)  two  vertex 
presentations  ;  one  head  lymg  in  advance  of  the  other,  the 
vertex  of  the  second  enters  the  brim  together  with  the  neck 
of  the  first,  and  neither  can  make  progress  ;  (2)  first  breech, 
second  vertex  presentation  ;  the  vertex  of  the  second  enters 
the  brim  in  advance  of  the  after-coming  head  of  the  first, 
and  the  two  heads  become  locked  either  chin  to  chin,  side 
by  side,  occiput  to  chin,  or  occiput  to  occiput ;  (3)  the  first 
presents  by  the  vertex  or  breech,  the  second  transversely. 
Li  varieties  (1)  and  (2),  natural  dehvery  is  possible  if  the 
pelvis  is  large,  the  uterine  contractions  are  powerful,  and  the 
foetuses  are  small  ;  when  these  conditions  are  not  present, 
and  invariably  in  the  third  variety,  insuperable  obstruction 
to  natural  dehvery  will  result.  Locking  occurs  quite  as 
frequently  with  binovular  as  with  uniovular  twins. 

Management. — Since  the  first  child  almost  invariably 
presents  by  the  head  or  breech,  its  delivery  may  be  left  to 
the  natural  efforts.  In  some  cases  of  binovular  twdns  with 
independent  placentae,  the  first  after-birth  may  immediately 
follow  the  dehvery  of  the  first  child.  This  is,  however, 
quite  micommon  ;  as  a  rule  both  placentae  follow  the  birth 
of  the  second  child.  Usually  the  uterine  contractions  cease 
for  fifteen  to  thirty  minutes  after  the  birth  of  the  first  child  ; 
then  they  return,  and  the  second,  if  presenting  favourably, 
is  quickly  dehvered,  for  the  passages  have  been  already  fully 
dilated.  Occasionally  a  delay  of  many  hours  or  even  several 
days  may  intervene  between  the  natural  expulsion  of  the 
first  and  the  second  child.  A  vaginal  examination  should  be 
made  immediately  after  the  birth  of  the  first  child  to  recog- 
nise the  presentation  of  the  second  ;  if  vertex  or. breech, 
nothing  need  be  done  ;  if  transverse,  external  or  internal 
version  should  be  performed  ;  the  latter  will  be  usually  very 
easy  on  account  of  the  small  size  of  the  fcetus  and  the 
relaxed  condition  of  the  passages.  When  the  he  of  the  foetus 
is  longitudmal,  the  membranes  may  be  ruptured  artificially 
if  the  uteruie  contractions  do  not  return  effectively  in  half 
an  hour  ;  but  a  short  period  of  rest  for  the  uterus  is  natural 


TWIN  LABOUR  389 

and  probably  serviceable,  therefore  undue  haste  should  be 
avoided.  The  delivery  of  the  second  child  by  version  or 
forceps  can  safely  be  accelerated  as  soon  as  labour  pains 
have  been  re-established,  since  the  passages  have  been 
already  fully  dilated.  The  third  stage  should  be  conducted 
with  the  greatest  care  and  patience  ;  the  uterus  quickly 
becomes  exhausted,  and,  the  area  of  the  placental  site  being 
unusually  large,  the  risks  of  post-partum  haemorrhage  are 
increased.  When  dividing  the  cord  of  the  first  child 
between  two  ligatures  in  the  usual  manner,  care  should 
be  taken  to  tie  the  distal  ligature  securely,  for  if  an  anas- 
tomosis should  exist  between  the  two  placental  circulations 
(umbilical),  the  second  child  may  bleed  through  the  cord  of 
the  first. 

Twin  locking  is  dealt  with  by  sacrificing  the  first  child, 
which  is  usually  dead,  in  the  interests  of  the  second,  if  the 
foetal  entanglement  cannot  be  cleared  by  manipulation  under 
anaesthesia.  In  the  first  variety,  the  lower  head  may  be 
sometimes  extracted  after  pushing  up  the  upper  head  out  of 
the  way  ;  if  this  fails,  the  first  head  must  be  perforated  and 
crushed,  for  if  not  already  dead  the  chances  of  the  survival  of 
the  first  child  are  necessarily  endangered,  while  the  second 
child  has  not  yet  suffered  much  from  the  effects  of  labour.  In 
the  second  and  third  varieties,  the  first  foetus  will  almost 
inevitably  perish  ;  it  may  be  decapitated,  or  the  head 
perforated,  and  after  dehvering  it  an  attempt  should  be 
made  to  save  the  second  by  the  application  of  forceps  or  by 
version. 

Prolapse  of  the  Umbilical  Cord  and  the  Limbs 

A  loop  of  the  umbilical  cord  sometimes  descends  below 
the  presenting  part  ;  when  this  occurs  before  the  membranes 
have  ruptured,  the  condition  is  called  presentation  of  the 
cord.  After  rupture  the  loop  will  descend  into  the  vagina  or 
may  even  protrude  at  the  vulva  ;  this  is  prolapse  of  the 
cord. 

Causes. — Descent  of  the  cord  is  more  likely  to  occur  when 
the  presenting  part  imperfectly  fills  the  pelvic  brim  than 
when  the  conditions  are  normal  ;  it  is  therefore  chiefly  met 
with  in  presentations  of  the  breech  or  shoulder,  when  there  is 


390  ABNORMAL   LABOUR 

pelvic  contraction,  liydr amnios,  or  twins,  or  when  the  foetus 
is  uniisualh"  small,  as  m  premature  labour  ;  other  conditions 
which  favour  its  occurrence  are  placenta  praevia,  an  abnor- 
mally long  cord,  and  the  lax  condition  of  the  uterus  found  in 
multiparse. 

Diagnosis. — The  looj^  of  cord  is  easily  recognised  whether 
the  membranes  are  intact  or  ruptured.  If  the  foetus  is  dead 
and  pulsation  has  ceased,  pi'esentation  of  the  cord  may  be 
mistaken  for  a  hand  or  foot,  but  with  j^rolajjse  no  mistake  is 
possible. 

Risks. — Prolapse  of  the  cord  does  not  increase  the 
maternal  risks  of  labour,  except  in  so  far  as  the  manipula- 
tions requhed  for  its  replacement  uivolve  slight  additional 
risks  of  sepsis.  The  foetus  is  in  great  danger  of  death  by 
asphyxia  from  compression  of  the  cord  between  the  present- 
ing part  and  the  pelvic  wall,  or  the  lip  of  the  imj)erfectly 
dilated  cervix  ;  the  foetal  mortahty  in  this  condition  is  about 
25  per  cent.  The  risks  are  greater  when  the  presentation  is 
a  vertex  than  in  abnormal  presentations,  for  serious  com- 
pression can  hardly  be  avoided  when  the  head  is  in  the  brim. 
Descent  in  front  of  the  head  (anterior)  is  more  dangerous 
than  descent  behmd  it  (posterior),  for  in  the  latter  the  cord 
may  lie  near  one  of  the  sacro-iliac  sjaichondroses  and  thus 
entirely  escajDC  compression,  while  in  the  former  the  loop  is 
certam  to  be  compressed  between  the  head  and  the  anterior 
pelvic  wall.  If  in  a  flat  pelvis  the  loop  comes  down  at  the 
side  so  as  to  lie  in  the  long  transverse  diameter,  it  is  very 
favourabh^  2^1^^®*^  to  avoid  compression.  The  risk  is  less  in 
a  multipara  than  in  a  primigravida,  for  in  the  former  labour 
can  be  terminated  more  rapidly. 

Management., — "VATien  it  is  found  that  pulsation  in  the 
cord  has  entirely  ceased  the  foetal  heart  should  be  auscul- 
tated, and  if  no  sounds  are  heard,  the  case  may  be  left  to 
termmate  naturally,  as  the  foetus  is  dead.  If  compression 
of  the  cord  has  lasted  but  a  short  time,  the  heart  ma}^  con- 
tinue to  beat.  When  the  foetus  is  still  living  interference  in 
its  interest  is  required. 

Presentation  of  the  cord  is  best  treated  by  jDOsture.  The 
aim  of  postural  management  is  to  place  the  patient  in  an 
attitude  in  which  the  fundus  of  the  uterus  lies  at  a  lower 
level  than  the  cervix,  so  that  the  action  of  gravity  will 


PROLAPSE   OF  THE  CORD 


391 


promote  the  return  of  the  presenting  loop  into  the  uterine 
cavity.  The  most  effectual  method  is  to  place  the  patient 
in  the  genu-pectoral  position  (Fig.  205),  in  which  the  body  is 
supported  upon  the  knees  and  the  upper  part  of  the  chest, 
the  arms  being  folded  beneath  it.  Another  less  effectual, 
but  also  less  troublesome  method,  is  the  knee-elbow  position, 
in  which  the  body  rests  upon  the  knees  and  forearms  (Fig. 
206).  The  knee-chest  is  more  effectual  than  the  knee-elbow 
position,  because  in  the  former  the  fundus  lies  at  a  relatively 


Fig.  205. — The  Knee-Cliest  (Genu-Pectoral)  Position. 

lower  level  than  in  the  latter.  Both  of  these  postures  are 
very  irksome,  and  cannot  be  maintained  for  more  than  ten 
to  fifteen  minutes  at  a  time  ;  the  patient  should  then  be 
placed  upon  her  side,  and  the  postural  treatment  resumed 
after  an  interval.  In  hospital  practice  the  Trendelenburg 
position  has  been  employed,  and  with  a  suitable  table  it  is 
possible  to  obtain  a  posture  in  which  the  patient  is  nearly 
upside  down  ;  but  it  is  obviously  unsuitable  for  general  use. 
These  postures  frequently  fail  to  effect  reduction.  The 
greatest  care  should  be  taken  to  preserve  the  membranes, 
for  while  they  remain  intact   there  is  little  or  no  risk  of 


392 


ABNORI^IAL  LABOUR 


compression.  The  possibility  of  pelvic  contraction  must  be 
remembered,  but  no  other  treatment  is  required  at  this  stage, 
as  the  foetus  is  not  in  immediate  danger. 

Prolapse  of  the  cord  with  a  partially  dilated  cervix  should 
in  the  first  instance  be  treated  by  digital  reposition.  An 
anaesthetic  is  administered,  the  gloved  hand  passed  into  the 
vagina,  and  the  cord  then  pushed  into  the  uterus  well  above 
the  presenting  part.  In  vertex  presentation  a  tight  abdo- 
minal binder  may  then  be  applied,  to  keep  the  presentmg 
part  well  down  in  the  pelvic  brim,  and  so  prevent  recurrence 


Fig.  206. — The  Knee-Elbow  Position. 

of  the  prolapse.  With  the  same  object,  in  breech  presenta- 
tion a  leg  should  be  pulled  down  into  the  vagina.  Instru- 
mental methods  of  reposition  are  also  sometimes  adopted, 
but  they  are  inferior  to  the  digital  method,  for  by  the  former 
a  portion  of  the  loop  may  easily  be  left  in  a  dangerous 
position,  unkno^Ti  to  the  operator.  A  simple  repositor  can 
be  constructed  from  a  piece  of  narrow  tape  and  a  gum-elastic 
catheter  (Fig.  207).  A  suitable  length  of  tape  is  boiled,  and 
the  catheter  is  sterilised  and  prepared  by  making  a  counter- 
opening  o^Dposite  the  eye  ;  through  this  the  ends  of  the  tape 
are  then  threaded.  The  loop  of  tape  is  now  made  to  encircle 
the  prolaj)sed  Ioojd  of  cord  and  is  then  drawn  sufficiently 


PROLAPSE  OF  THE  CORD 


393 


tight  to  hold  it  without  undue  compression.  The  catheter, 
along  with  the  snared  loop  of  cord,  is  next  pushed  up  into 
the  uterus  as  high  as  possible,  and  left  there  to  be  expelled 
with  the  body  of  the  foetus. 

If  in  a  vertex  presentation  the  cervix  is  not  sufficiently 
dilated  to  allow  reposition  to  be  properly  effected,  or  if  the 
cord  comes  down  again  after  having  been  replaced,  a  de 
Ribes'  bag  should  be  introduced  after  careful  reposition  of 
the  prolapsed  loop  ;  this  will 
effectually  prevent  recurrence, 
in  addition  to  dilating  the 
cervix.  In  a  breech  presenta- 
tion the  risk  of  compression  is 
decidedly  less.  If  the  cord 
can  be  properly  replaced,  it  is 
sufficient  to  pull  down  a  leg 
and  leave  delivery  to  nature  ; 
if  there  is  difficulty  in  re- 
placing it,  the  dilating  bag 
should  be  employed. 

When  the  cervix  is  fully 
dilated,  prolapse  of  the  cord 
should  in  all  cases  be  treated 
by  immediate  delivery  by 
version  or  forceps.  If  the 
head  has  passed  the  brim,  the 
cord  cannot  possibly  be  re- 
placed nor  can  version  be  per- 
formed ;  rapid  extraction  with  forceps  offers  the  best  chance 
of  saving  the  child. 

Prolapse  of  Limbs. — Occasionally  a  vertex  presenta- 
tion is  complicated  by  descent  of  the  arm  or  the  leg,  so  that 
the  hand  or  foot  enters  the  pelvic  brim  along  with  the  head 
(Fig.  208).  This  occurs  more  frequently  with  premature 
labour  or  with  twins,  or  when  the  pelvis  is  contracted, 
than  under  normal  conditions.  Such  a  presentation  is 
usually  called  complex.  Prolapse  of  the  foot  is  much  rarer 
than  prolapse  of  the  hand.  When  the  head  is  of  small  size, 
prolapse  of  the  hand  does  not  prevent  natural  delivery  ;  if, 
however,  the  cervix  is  fully  dilated,  the  hand  should  be 
replaced  under  anaesthesia,  and  the  head  then  delivered  with 


Fig.  207. — Instrumental  Eeposi- 
tion  of  Prolaj)sed  Cord. 
(Galabin.) 


394 


ABNORMAL   LABOUR 


forceps,  care  being  taken  to  avoid  compression  of  the  arm 
by  the  blades.  EarHer  in  labour,  when  the  cervix  is  incom- 
pletely dilated,  version  should  be  performed. 

In  a  transverse  presentation  both  the  arm  and  the  leg 
sometimes  become  prolapsed,  and  along  with  them  a  loop  of 
the  cord  may  descend.  This  gives  a  complex  presentation 
which    offers    considerable    difficulties    in    diagnosis.     The 


Fig.  208. — Presentation  of  the  Head  and  Arm. 
(Galabin  and  Blacker.) 

treatment  is  version  in  all  cases,  when  the  labour  is  not  too 
far  advanced  for  this  operation  to  be  safely  performed. 


Pelvic  Contraction 

The  female  pelvis  may  be  variously  altered  in  size  alone, 
or  in  size  and  shape,  by  errors  of  development,  by  local  or 
general  bone  disease,  or  by  the  results  of  accident.     The 


PELVIC   CONTRACTION  395 

frequency  of  pelvic  contraction  varies  greatly  in  different 
localities,  being  much  more  frequent  in  large  cities  than  in 
rural  districts.  Among  over  50,000  labours  in  the  Uni- 
versity Klinik  in  Vienna  between  1878  and  1895,  pelvic 
contraction  occurred  in  25  per  cent,  of  all  cases.  At  Queen 
Charlotte's  Hospital,  London,  it  was  found  that  in  10,000 
labours  4  per  cent,  of  cases  of  contracted  pelvis  occurred. 
A  large  number  of  different  types  exist,  but  most  of  them  are 
of  rare  occurrence,  and  their  effects  upon  the  course  of  labour 
have  not  received  detailed  individual  study.  Two  types  are, 
however,  of  comparatively  frequent  occurrence,  and  must 


Fig.  209. — Generally  Contracted  Pelvis. 

therefore  be  fully  considered  ;  the  others  will  be  only  briefly 
referred  to. 

1.  The  Generally  Contracted  Pelvis  (Small  round  pelvis  : 
Pelvis  sequabihter  justo-minor). — This  form  of  pelvis 
(Fig.  209)  differs  from  the  normal  mainly  in  size,  all  the 
diameters  being  proportionately  diminished,  while  the  general 
shape  is  preserved.  Minor  differences,  however,  exist  in  the 
inclination  of  the  plane  of  the  brim  and  in  the  curvature  of 
the  sacrum.  The  promontory  lies  at  a  level  higher  than 
normal  ;  and  the  angle  made  by  the  plane  of  the  brim  with 
the  horizon  is  therefore  somewhat  increased  (compare 
Figs.  106  and  209).  The  concavity  of  the  sacrum  from  side 
to  side  is  deepened,  while  that  from  above  downwards  is 
diminished  ;  these  changes  slightly  exaggerate  the  diminu- 
tion of  the  antero-posterior  diameter  of  the  cavity.  All  the 
dimensions  of  the  outlet  are  proportionately  reduced.     The 


396  ABNORMAL  LABOUR 

shape  of  the  false  pelvis  is  unaffected,  but  its  diameters  are 
also  dimuiished.  Sometimes  pelves  of  this  variety  approxi- 
mating to  the  male  type  are  met  with. 

Nothing  is  definitely  known  of  the  causes  of  this  form  of 
pelvic  contraction  ;  it  is  said  to  be  the  variety  most  com- 
monly met  with  in  America  (Edgar),  but  in  European 
countries  the  rachitic  forms  predommate.  It  may  be  met 
with  in  women  whose  development  is  otherwise  normal  ; 
it  is  also  frequently  found  in  dwarfs  who  are  not  the  subjects 
of  rickets. 

2.  The  Flat  Pelvis. — The  characteristic  features  of  this 
form  of  contracted  pelvis  are  :  (1)  reduction  in  length  of  the 
conjugate  diameter  of  the  brim,  and  (2)  an  abnormal  curva- 
ture of  the  ihac  crests.  Two  varieties  are  distinguished — 
viz.,  one  in  which  no  other  changes  than  those  just  men- 
tioned are  found,  and  one  in  which  changes  also  occur  in  the 
pelvic  cavity  and  outlet.  By  some  writers  these  varieties 
are  respectively  termed  non-mchitic  and  rachitic,  the  latter 
being  attributed  to  rickets  in  all  cases.  By  others,  both 
varieties  are  attributed  to  rickets,  and  tjiey  are  then  re- 
spectively termed  the  elliptical  or  simple  flat  pelvis,  and  the 
reniform  flat  pelvis.  The  latter  is  clearly  rickety,  but  the 
evidence  upon  which  the  former  is  attributed  to  rickets  is 
inconclusive,  and  we  shall  therefore  adopt  the  names 
non-rachitic  and  rachitic  flat  pelvis  for  these  two  varieties. 

In  the  non-rachitic  flat  pelvis  the  deformity  is  never 
extreme  :  the  patient  is  usually  weU  developed  in  other 
respects,  and  shows  no  rickety  changes  in  any  other  part 
of  the  skeleton.  The  anterior  portions  of  the  ihac  crests  are 
not  incurved  to  the  same  extent  as  in  the  normal  pelvis  ; 
consequently  the  distance  between  the  anterior  superior 
iliac  spines  {interspinous  diameter)  does  not  maintain  its 
usual  proportion  to  the  distance  between  the  summits  of 
the  ihac  crests  {intercristal  diameter).  This  alteration  has  no 
uifluence  upon  labour,  but  is  useful  clinically,  in  fumishmg 
an  indication  of  the  condition  of  the  pelvic  brim.  The  con- 
jugate diameter  of  the  brim  may  be  reduced  to  3  inches 
(7*5  cm.),  but  in  this  form  of  flat  pelvis  it  is  xqtj  rare  to  find  a 
greater  reduction  than  this.  This  change,  to  which  the 
characteristic  flattening  is  due,  appears  to  be  caused  by  slight 
forward   displacement    of   the   upper   part    of   the   sacrum. 


PELVIC  CONTRACTION 


397 


The  transverse  diameter  of  the  brim  is  increased,  either 
absolutely  (over  5|  inches),  or  at  any  rate  relatively  to  the 
length  of  the  conjugate.  The  oblique  diameters  of  the  brim, 
as  well  as  all  those  of  the  cavity  and  outlet,  are  unaltered. 

In  the  rachitic  flat  pelvis  the  deformity  may  be,  and 
usually  is,  much  more  pronounced  than  this.  Such  evi- 
dences of  rickets  will  be  found  as  curvature  of  the  shafts 
of  the  long  bones  and  enlargement  of  their  epiphyses, 
beading  and  bending  of  the  ribs,  and  perhaps  diminutive 
stature.  In  marked  cases  the  pelvis  shows  a  series  of  charac- 
teristic changes.     The  outward  displacement  of  the  anterior 


Fig.  210. — Eachitic  Flat  Pelvis,  minor  degree  :  showing  Eeduction 
of  the  Conjugate  and  Flattening  of  the  Sacrum. 


portion  of  the  iliac  crests  is  well  marked,  the  iliac  fossae  being 
directed  nearly  forwards,  instead  of  forwards  and  inwards 
(compare  Figs.  104  and  210).  The  sacrum,  softened  by 
disease,  has  been  both  bent  and  displaced  forwards  by  the 
pressure  of  the  body-weight  ;  the  promontory  has  therefore 
been  carried  nearertothe  symphysis,  and  the  concave  anterior 
surface  has  become  flat,  or  it  may  be  even  slightly  convex 
(Figs.  210  and  212).  In  addition,  rotation  of  the  whole  bone 
has  occurred  round  a  horizontal  axis  passing  through  the 
centre  of  the  sacro-iliac  synchondroses  ;  this  brings  the 
promontory  still  nearer  the  symphysis,  and  carries  the  coccyx 
further  away  from  it.     The  outlet  of  a  rachitic  fiat  pelvis,  on 


398 


ABNORMAL   LABOUR 


the  other  hand,  is  larger  than  normal  (Fig.  212).  Its  antero- 
posterior diameter  is  increased  by  the  rotation  of  the  sacrum 
just  described.  Under  the  pressure  of  the  body-weight 
transmitted  by  the  innominate  bones  through  the  hip-joints 
to  the  legs,  the  lateral  pelvic  walls  bulge  outwards,  increasing 
the  transverse  diameter  of  the  brim  ;  also  the  ischial 
tuberosities  are  carried  further  apart,  thus  increasing  the 
width  of  the  pubic  arch  and  the  length  of  the  transverse 
diameter    of    the   outlet.     On  looking   into   such  a   pelvis 


Fig.  211. — EacHtic  Flat  Pelvis,  extreme  degree  :  altered  Curvature 

of  the  Iliac  Crests. 

The  relative  increase  in  the  transverse  diameter  is  well  shown. 

from  below,  the  large  dimensions  of  the  outlet  contrast 
with  the  contracted  conjugate  of  the  brim  and  the  greatly 
exaggerated  prominence  of  the  sacral  promontory  (compare 
Figs.  212  and  216). 

Sometimes  ui  a  rachitic  flat  pelvis  the  bodies  of  the  pubic 
bones  are  distmctly  incurved  (beaked),  encroaching  still 
further  upon  the  conjugate  of  the  brim  ;  when  the  latter 
deformity  is  well  marked  the  pelvis  is  sometimes  called,  from 
the  shape  of  the  brim,  the  figure-of-eight  rachitic  flat  j^dvis. 

The  changes  in  a  marked  case  of  rachitic  flat  pelvis  may 
be  summarised  as  follows  ; 


PELVIC  CONTRACTION 


399 


False  Pelvis. — Relative  increase  in  interspinous  diameter. 

Brim. — Conjugate  diminished,  transverse  increased, 
shape  reniform  or  figure-of-eight. 

Outlet.- — Transverse  and  antero-posterior  increased,  pubic 
arch  widened,  or  in  some  cases  narrowed  (beaked). 

Cavity. — Anterior  surface  of  sacrum  flat  or  convex. 

The  generally  contracted  flat  pelvis  (flat  justo-minor  pelvis) 
is  a  form  in  which  diminutive  size  is  associated  with  rachitic 
flattening  ;  the  shape  is  that  of  the  rachitic  flat  pelvis,  but 
all  the  diameters  are  diminished  in  length.  This  form  of 
pelvis  is  usually  associated  with  advanced  rachitic  changes 


Fig.  212.— The  Outlet  of  a  Elat  Pelvis  seen  from  below. 


in  the  skeleton  generally,  one  of  the  most  frequent  of  these 
being  lateral  curvature  of  the  spine  (scoliosis).  When  this 
change  is  present  the  resulting  pelvic  contraction  is  asym- 
metrical or  oblique  (Fig.  213).  If  the  spine  is  fairly  straight, 
the  generally  contracted  flat  pelvis  remains  symmetrical. 
The  resulting  deformity  is,  in  either  case,  extreme,  and  gives 
rise  to  more  serious  difficulty  in  labour  than  either  the  flat 
pelvis  or  the  small  round  pelvis. 

In  the  Vienna  statistics  already  quoted,  the  four  varieties 
— ^non-rachitic  flat  pelvis,  rachitic  flat  pelvis,  generally  con- 
tracted pelvis,  and  generally  contracted  flat  pelvis,  accounted 
for  about  96  per  cent,  of  all  cases  of  pelvic  contraction  ;  the 
remaining  varieties  are  accordingly  very  uncommon.     The 


400 


ABNORMAL  LABOUR 


extreme  cases  of  pelvic  contraction  met  with  in  this  country 
usually  belong  to  the  generally  contracted  flat  variety. 

Generally  enlarged  Pelvis  (Pelvis  sequabiliter  justo-major). 
— This  is  not  a  contracted  pelvis  at  all,  but  a  pelvis  of  greater 
size  than  the  normal,  though  proportionate  in  all  its  dia- 
meters. Its  influence  is  not,  as  a  rule,  unfavourable,  but  it 
may  be  one  of  the  factors  in  the  causation  of  yreciyitate 
labour  (see  p.  442). 

Diagnosis  of  Pelvic  Contraction. — While  the  presence  of 
a  contracted  pelvis  may  be  surmised  from  the  diminutive 


Pig.  213. — Generally  contracted  Eachitic  Flat  Pelvis,  witli  Lateral 
Obliquity  due  to  Scoliosis. 

stature  of  the  patient,  from  general  evidences  of  rickets  or 
other  bone  diseases,  from  lameness,  or  from  the  pendulous 
condition  of  the  abdomen  in  pregnancy,  it  can  only  be 
certainly  recognised  by  measurement.  In  the  case  of  a 
multipara  an  obstetric  history  of  previous  difflcult  labour, 
in  which  the  child  was  born  dead  or  did  not  survive  more  than 
a  day  or  two,  should  always  arouse  suspicion  of  the  presence 
of  pelvic  deformity,  although  this  will  not  in  all  such  cases 
be  discovered.  The  anatomical  pelvic  diameters  described 
on  p.  257  cannot  be  measured  clinically,  but  certain  other 
measurements  of  the  living  subject  can  be  made,  from  which 
the  size  of  the  true  pelvis  may  be  inferred  with  approximate 


PELVIMETRY 


401 


accuracy.  Such  measurements  must  be  made  with  great 
care,  as  it  is  very  important  for  practical  purposes  to  note 
the  degree  of  contraction  present  in  any  given  case. 

The  measurements  of  the  pelvis  which  can  be  taken  in 
the  living  subject  are  external  and  internal.  They  should, 
whenever  possible,  be  taken  with  the  pelvimeter  ;  some, 
however,  are  best  measured  with  the  fingers.  Methods  of 
estimating  the  size  of  the  pelvis  are  called  clinical  'pelvimetry. 
The  most  useful  form  of  pelvimeter  for  external  measure- 
ments is  that  of  Collin, 
shown  in  Fig.  214.  It 
consists  of  a  pair  of  calli- 
pers, furnished  with  an 
index  which  shows  the 
distance  between  the 
points  in  all  positions. 
The  points  can  be  sepa- 
rated from  one  another 
by  opening  the  instru- 
ment like  a  pair  of  for- 
ceps, or  in  the  reverse 
direction  by  crossing  the 
blades.  The  latter  posi- 
tion is  used  for  mea- 
suring the  transverse 
diameter  of  the  outlet 
by  pressing  the  crossed 
points  deeply  into  the 
perineum,  so  as  to  bring 
them  in  contact  with  the 
inner  borders  of  the  is- 
chial tuberosities.  The  instrument  can  also  be  used  in  this 
position  for  internal  measurements.  In  using  it  for  external 
measurements  the  instrument  should  be  held  by  the  points 
— one  in  each  hand,  and  carefully  adjusted  to  the  required 
diameter,  by  firm  pressure  against  the  bone  (Fig.  217).  The 
index  is  then  read  off. 

External  Measurements. — (1)  Interspinous  Diameter.  This 
is  the  distance  between  the  outer  borders  of  the  anterior 
superior  iliac  spines  ;  its  average  length  is  10  inches  (25  cm.). 

(2)  Intercristal  Diameter.     This  is  the  distance  between 
E.M.  26 


Fig.  214. — Pelvimeter. 


402 


ABNORI^IAL   LABOUR 


the  outer  borders  of  the  iHac  crests  where  these  are  widest 
apart ;  the  points  of  the  pelvimeter  are  moved  to  and  fro 
until  the  position  of  maximum  separation  has  been  found, 
which  is  usually  about  2^  inches  behind  the  anterior  superior 
spines.  Its  average  length  is  11  inches  (27-5  cm.).  From 
observations  on  the  cadaver  (Sandstein)  it  appears  that 
this  diameter  approximately  represents  twice  the  length 
of  the  transverse  diameter  of  the  brim  ;  and  as  the  latter  is 
very  difficult  to  measure  clinically,  this  relation  becomes  one 


Fig.  215. — Tlie  Lumbo-sacral  Spine  with  a  Normal  Pelvis. 
(Modified  from  Bumm..) 


of  practical  importance.  In  a  normally  shaped  pelvis  the 
intercristal  diameter  is  an  inch  longer  than  the  interspinous 
diameter.  This  proportion  is  preserved  in  the  generally 
contracted  pelvis,  although  the  length  of  both  may  be 
dimmished,  but  in  the  flat  pelvis  there  is  less  than  an  inch 
of  difference  between  them,  and  m  well-marked  rachitic 
flattening  the  interspinous  may  even  be  equal  in  length  to 
the  intercristal  diameter. 

(3)  External  Conjugate  Diameter.  This  is  the  distance 
between  the  tip  of  the  spine  of  the  last  lumbar  vertebra  and 
the  centre  of  the  upper  border  of  the  symphysis  pubis      This 


PELVIMETRY 


403 


diameter  can  be  best  measured  in  the  erect  position.  The 
posterior  bony  point  is  difficult  to  find  in  fat  subjects,  but  in 
thin  women  there  is  no  difficulty.  Whenever  practicable 
the  lumbar  spines  should  be  counted,  and  a  palpable  pit  or 
depression  will  usually  be  found  just  below  the  spine  of  the 
fifth  vertebra.  One  point  of  the  pelvimeter  is  adjusted  to 
this  depression,  and  the  other  pressed  carefully  and  firmly 
against  the  pubes  in  the  position  described.  The  average 
length  of  this  diameter  is  7f  to  8  inches  (20  cm.).     When  the 


Fig.  216. — Estimating  the  Width  of  the  Pelvic  Arch  by  Palpation. 
(Williams.) 


spine  of  the  last  lumbar  vertebra  cannot  be  clearly  felt,  it 
may  be  located  as  follows  :  the  position  of  the  two  posterior 
superior  iliac  spines  is  first  marked  upon  the  skin  ;  these 
points  are  then  united  by  a  horizontal  line  ;  a  point  1|  to 
If  inches  above  the  centre  of  this  line  will  indicate  the 
position  of  the  fifth  spine.  Shallow  depressions  can  often 
be  recognised  over  these  three  bony  points,  and  from  them 
a  rhomboidal  figure  may  be  constructed  upon  the  lumbo- 
sacral region  known  as  the  rhomboid  or  lozenge  of  Michaelis, 
the  lower  sides  being  formed  by  the  posterior  borders  of  the 

26—2 


404 


abxor:\l\l  labour 


glutei  maximi  muscles,  the  upper  sides  by  lines  joining  the 
fifth  lumbar  spme  to  the  posterior  superior  ihac  spine  on 
each  side.  The  relations  of  the  three  bony  points  to  one 
another  can,  however,  best  be  recognised  by  marking  out  a 
triangle  upon  the  back  as  in  Fig.  215  ;  the  base  fine  represents 
the  distance  between  the  posterior  superior  iliac  spines 
{posterior  interspinous  diameter).  The  length  of  the  latter 
is    variable,    and    consequently    little    importance    can    be 


Fig.  2 it.' — Measuiing  tlie  Ant ero -posterior  Diameter  of  the  Outlet. 

(Bumm.) 

attached  to  it  ;  the  average  is  placed  at  4  inches  (10  cm.)  in 
a  normal  pelvis. 

In  the  case  of  a  normal  jDclvis  3|  to  3f  inches  (9"o  to 
10  cm.)  must  be  deducted  from  the  external  conjugate 
diameter  to  obtain  the  true  conjugate  ;  if  the  pelvis  is 
flattened.  4  to  4 J  inches  (10  to  10' 5  cm.)  should  be  deducted 
in  order  to  allow  for  the  forward  displacement  of  the  U23per 
part  of  the  sacrum. 

(4)  The  size  of  the  pelvic  outlet  can  also  be  measured 
clinically  and  is  of  considerable  practical  importance.  The 
jDatient  should  lie  on  her  back  -^-ith  the  legs  flexed  and  the 
buttocks  brought  to  the  edge  of  the  couch.  The  width  of 
the  pelvic  arch  should  first  be  estimated  by  palpation  with 
the  thumb  in  the  manner  shown  in  Fig.  216.     After  a  Httle 


> 

I— I 

EH 


M 


PM 


« 


PELVIMETRY 


405 


experience  a  rough  estimate  of  the  arch  as  wide,  medium, 
or  narrow  may  be  made,  and  this  should  be  a  part  of  the 
routine  examination  of  all  primiparae.  The  actual  measure- 
ments need  only  be  made  when  a  suspicion  exists  of  con- 
traction. The  aid  of  an  assistant  is  required  for  these 
measurements.  The  antero -posterior  is  taken  from  the 
lower  border  of  the  symphysis  to  the  last  sacral  vertebra,  a 
quarter  of  an  inch  being  deducted  for  the  thickness  of  the 


/  / 


Fig.  218. — Measuring  the  Transverse  Diameter  of  the  Outlet. 
(Williams.) 


sacrum  (Fig.  217).  In  measuring  the  transverse  diameter 
the  inner  borders  of  the  ischial  tuberosities  are  first  defined 
with  the  thumbs  (Fig.  218),  and  the  distance  measured 
between  them. 

Internal  Measurements. — These  can  be  made  with  the 
fingers  alone,  or  with  an  internal  pelvimeter.  The  most 
important  diameter  to  be  estimated  by  this  method  is  the 
conjugate  of  the  brim. 

(1)  Diagonal  Conjugate.     This  is  the  distance  from  the 


406 


ABNORMAL   LABOUR 


centre  of  the  promontory  of  the  sacrum  to  the  centre  of  the 
lower  border  of  the  symphysis  (Fig.  219).  It  can  easily  be 
measured  with  the  fingers  when  the  pelvic  brim  is  con- 
siderably contracted,  but  it  caimot  be  taken  in  labour  when 
the  presenting  parf  is  fixed  in  the  brim.  In  common  with 
other  clinical  measurements,  it  has  the  disadvantage  that 
its  relation  to  the  true  conjugate  is  variable,  and  difficult 
to  estimate  precisely.  On  an  average  it  may  be  said  to  be 
from  ^  to  I  of  an  inch  longer  than  the  true  conjugate — i.e. 
4|   to    5   inches.     The   factors   which   affect   the   diagonal 


Pig.  219. — Measuring  the  Diagonal  Conjugate.     (Norris. 


conjugate  to  an  extent  which  it  is  difficult  to  estimate  are 
the  thickness  and  dej^th  of  the  symphysis,  and  the  angle 
which  it  forms  with  the  plane  of  the  brim.  This  measure- 
ment can  best  be  made  with  the  patient  lymg  on  her  back, 
the  thighs  flexed  and  supported  by  assistants,  and  the  but- 
tocks drawn  over  the  edge  of  the  bed  ;  it  can  also,  however, 
be  made  m  the  usual  obstetric  posture,  when  no  assistance 
will  be  required.  The  index  and  middle  fingers  are  passed 
into  the  vagina  and  pressed  upwards  and  backwards  until 
the  edge  of  the  promontory  can  be  felt  with  the  tip  of  the 
middle  finger.  In  a  pelvis  of  normal  size  it  is  usually 
impossible  thus  to  reach  the  promontory.     Care  must  be 


PELVIMETRY  407 

taken  not  "to  mistake  the  first  sacral  ridge  for  the  promontory, 
for  the  diameter  will  then  appear  to  be  longer  than  it  really 
is.  When  the  finger  is  in  contact  with  the  promontory  the 
bone  at  a  higher  level  can  be  felt  to  recede  so  as  to  become 
more  difficult  to  reach  ;  if  a  lower  sacral  ridge  is  touched  the 
finger  pushed  further  upwards  is  still  in  contact  with  the 
bone.  The  point  where  the  lower  border  of  the  symphysis 
comes  in  contact  with  the  hand  is  then  marked  off  with  the 
finger-nail,  and  after  withdrawing  the  fingers  the  measured 
distance  between  this  point  and  the  tip  of  the  middle  finger 
represents  the  length  of  the  diagonal  conjugate.  In  many 
cases  it  is  impossible  satisfactorily  to  measure  this  diameter 
except  under  anaesthesia  ;  this  is  especially  the  case  in 
minor  degrees  of  contraction. 

(2)  Various  methods  have  been  introduced  to  measure 
the  true  conjugate  and  transverse  directly  by  the  use  of  an 
internal  pelvimeter.  The  simplest  form  of  internal  pelvi- 
meter is  that  of  Skutsch,  which  may  be  used  for  both  the 
conjugate  and  transverse  diameters  of  the  brim.  This 
instrument  consists  of  a  pair  of  callipers  with  one  rigid  and 
one  flexible  arm,  joined  by  a  screw  but  not  furnished  with  an 
index.  In  measuring  the  transverse  the  internal  rigid  limb 
is  passed  into  the  vagina  and  first  guided  up  to  the  centre  of 
the  right  lateral  wall  of  the  pelvic  brim,  while  the  point  of 
the  flexible  limb  is  adjusted  to  the  tip  of  the  left  great 
trochanter.  The  instrument  is  then  withdrawn  and  the 
distance  between  the  points  measured  off.  The  rigid  limb 
is  again  passed  and  the  point  applied  to  the  centre  of  the  left 
lateral  .wall  of  the  brim,  the  external  limb  being  applied  to 
the  same  point  as  before.  The  instrument  is  then  with- 
drawn and  the  separation  of  the  points  again  measured. 
The  difference  between  the  two  measurements  represents 
the  length  of  the  transverse  diameter.  In  measuring  the 
conjugate  the  tip  of  the  rigid  limb  is  placed  against  the  centre 
of  the  promontory,  and  the  flexible  limb  adjusted  to  the 
centre  of  the  upper  border  of  the  symphysis  ;  the  second 
measurement  is  taken  with  the  rigid  limb  placed  upon  the 
centre  of  the  posterior  surface  of  the  symphysis  at  its  upper 
border.  The  difference  between  them  represents  the  true 
conjugate.  In  practice  this  instrument  is  difficult  to  work 
with   precision,    and   requires   an   anaesthetic.     Experience 


408  ABNORMAL   LABOUR 

shows  that  a  rough  estimate  of  the  size  of  the  transverse 
diameter  may  be  obtained  by  the  simple  expedient  of 
endeavouring,  with  two  fingers  in  the  vagina,  to  trace  the 
pelvic  brim  from  the  symphysis  back  to  the  promontory.  If 
the  transverse  is  of  normal  length  this  is  very  difficult,  even 
under  anaesthesia,  but  if  contracted  it  will  be  quite  prac- 
ticable. This  method  can  be  controlled  by  halving  the 
intercristal  diameter. 

(3)  Another  method  of  internal  pelvimetry  must  be 
mentioned — viz.,  the  method  of  Johnson.  This  consists  in 
passing  the  whole  hand  into  the  vagina,  and  endeavouring 
to  fit  the  closed  fist  into  the  conjugate  of  the  brim.  The 
author  of  this  method  elaborated  it  to  such  an  extent  as  to 
define  a  series  of  positions  of  the  thumb  and  fingers,  each  of 
which  represented  a  definite  length  from  4  to  3  inches,  and 
he  claimed  that  he  was  thus  able  to  measure  the  conjugate 
precisely.  It  is  clear  that,  as  hands  are  not  of  uniform  size, 
there  is  abundance  of  room  for  error,  which  can  only  be  elimi- 
nated by  taking  careful  measurements  of  the  hand  in  the 
various  attitudes  described  by  Johnson  before  attempting 
to  apply  it.  A  further  objection  is  that  the  hand  cannot 
be  passed  into  the  vagina  except  immediately  after  labour, 
and  the  method  is  therefore  not  available  at  the  time  when 
measurements  are  most  required. 

Clinical  pelvimetry  clearly  yields  results  which  are  by  no 
means  precise.  One  measurement  must  be  controlled  as  far 
as  possible  by  others,  but  ultimately  the  carefully  corrected 
diagonal  conjugate  is  most  to  be  relied  upon.  The  most 
favourable  moment  for  accurately  measuring  the  pelvis  is 
immediately  after  delivery,  the  patient  being  anaesthetised. 
No  opportunity  should  be  lost  of  taking  measurements  at  this 
time  in  cases  of  contracted  pelvis,  so  that  previous  diagnosis 
may  be  confirmed  or  corrected.  For  practical  purposes  a 
rough  estimate  of  the  transverse  is  also  necessary  in  order  to 
determine  the  shape  of  the  pelvic  brim.  Photography  by 
X-rays  can  be  employed  to  show  the  shape  of  the  pelvis  with 
striking  success  except  in  advanced  pregnancy.  It  is  also 
possible  by  the  accurate  methods  of  radiography  now 
practised  to  estimate  the  diameters  of  the  brim  with  a  fair 
amount  of  precision.  Another  useful  method  of  control, 
however,   exists   in   determining   for    any   given    case    the 


CONTRACTED   PELVIS  409 

relation  in  size  between  the  pelvis  and  the  foetal  head. 
This  can  be  done  during  pregnancy  as  well  as  in  labour, 
and  is  usually  employed  in  deciding  upon  the  mode  of 
treatment  required  in  pelvic  contraction.  This  method  will 
be  described  in  another  place  (p.  421). 

Pregnancy  and  Labour  in  Contracted  Pelves. — The  course 
of  pregnancy  is  not  affected  to  any  considerable  extent  by 
pelvic  contraction.  There  is  no  greater  risk  of  abortion, 
and  only  a  slightly  greater  risk  of  premature  labour,  than 
when  the  pelvis  is  normal  ;  the  development  of  the  foetus  is 
not  affected  in  any  way,  the  full-time  child  being  of  average 
size  and  weight.  Towards  the  close  of  pregnancy  the  uterus 
may  become  anteverted,  causing  a  more  or  less  marked 
condition  of  '  pendulous  belly.'  This  is  mainly  due  to  the 
unusual  height  of  the  presenting  part,  which  cannot  enter  the 
narrow  pelvis  ;  the  level  of  the  fundus  is  consequently  higher 
than  usual,  and  when  spinal  curvature  is  associated  with 
pelvic  contraction  the  forward  displacement  of  the  uterus 
becomes  very  marked.  Multiparity,  with  lax  abdominal 
walls  and  diminutive  stature,  still  further  exaggerate  the 
anteversion.  Pelvic  contraction  has  been  already  alluded 
to  as  an  occasional  cause  of  incarceration  of  the  retroverted 
gravid  uterus  at  the  fourth  month. 

The  general  course  of  labour  is  modified  by  pelvic  con- 
traction in  various  ways  : 

(1)  Abnormal  presentations  are  three  or  four  times  com- 
moner in  contracted  than  in  normal  pelves  ;  the  reasons  for 
this  have  already  been  mentioned. 

(2)  Prolapse  of  the  cord  is  much  commoner  than  in 
normal  pelves. 

(3)  When  natural  delivery  occurs,  labour  is  prolonged  and 
the  mechanism  is  modified. 

(4)  Unless  the  true  conjugate  is  at  least  3|  inches,  even 
with  artificial  aid  the  survival  of  the  child  is  seriously 
jeopardised. 

(5)  The  maternal  risks  are  increased  by  the  greater  length 
and  difficulty  of  the  labour,  and  by  the  frequent  necessity 
of  employing  artificial  methods  of  delivery. 

(6)  The  fcetal  risks  are  increased  in  natural  delivery  by 
severe  compression  of  the  head  during  its  passage  through 
the  narrow  pelvis,  and  under  other  circumstances  by  the 


410  ABNORMAL  LABOUR 

operations  required  to  effect  delivery,  some  of  which  involve 
the  destruction  of  the  fcstus. 

The  clinical  phenomena  are  modified  in  several  important 
particulars.  When  the  degree  of  obstruction  is  considerable, 
violent  uterine  action  may  be  aroused,  which  may  either  pass 
into  tonic  contraction,  or  more  rarely  give  place  to  secondary 
inertia.  The  cervix  dilates  slowly,  and  the  first  stage  is 
therefore  prolonged  ;  the  bag  of  waters  is  voluminous  and 
frequently  ruptures  prematurely ;  great  enlargement  of  the 
anterior  lip  of  the  cervix,  from  oedema,  may  occur  from  the 
compression  of  the  lower  uterine  segment  between  the  head 
and  the  pubes.  A  large  caput  succedaneum  forms  in  vertex 
or  face  presentations  ;  it  may  be  so  large  as  to  present  at  the 
vulva  before  the  head  has  passed  the  brim.  In  a  rachitic 
flat  pelvis  the  expulsion  of  the  head  through  the  vulva  is 
often  unusually  rapid  when  the  patient  is  a  multipara  ;  in  the 
generally  contracted  pelvis  it  is  always  slow  and  difficult. 

The  shape  of  the  pelvis  and  the  length  of  the  conjugate 
are  the  factors  which  chiefly  influence  the  course  of  labour. 
With  the  three  common  varieties  of  contracted  pelvis  in 
cases  which  are  allowed  to  go  to  term,  spontaneous  delivery 
occurs  in  from  40  to  63'3  per  cent.  ;  the  simple  flat  pelvis  is 
the  most  favourable  in  this  respect,  then  the  generally 
contracted  pelvis,  and  lastly  the  rachitic  flat  pelvis.  The 
frequency  of  spontaneous  delivery  at  term  diminishes 
rapidly  in  proportion  to  the  diminution  of  the  conjugate. 
Thus  the  Vienna  statistics  previously  referred  to  show  the 
following  percentages  : 


c.v. 

.     9i  cm. 

=     (3-8  in.) 

spontaneous 

75-6  % 

0.  Y. 

.     9     ,, 

=     (3-6  „   ) 

jj 

58-7  % 

C.V. 

■         .     8+  „ 

=      (3-4  ,.  ) 

,, 

49-7  % 

C.V. 

.     8     ,, 

=     (3-2  „  ) 

,, 

25-0  % 

Mechanism. — I.  Flat  Pelvis. — (a)  In  head  presentation 
the  mechanism  is  usually  modified  in  the  following  manner, 
although  many  variations  may  be  met  with  :  The  head 
enters  the  brim  more  or  less  extended,  and  in  the  transverse 
instead  of  the  oblique  diameter.  Parietal  obliquity  is 
usually  well  marked  in  the  second  stage  of  labour.  When  the 
contraction  of  the  conjugate  is  considerable,  lateral  dis- 
placement of  the  head  towards  the  side  occupied  by  the 
occiput  occurs  early  in  labour  ;  this  is  rendered  possible  by 


CONTRACTED   PELVIS 


411 


the  increased  length  of  the  transverse  diameter,  and  tends 
to  promote  flexion,  because  the  sinciput  is  delayed  in  the 


iFiG.  220. — Labour  in  Flat  Pelvis  :  Eotation  of  the  Head  in 
Passing  the  Brim.     (Clarence  Webster.) 

1.  Well-marked  anterior  parietal  obliquity.     2.  Forward  rotation.     3.  Backward  rotation. 

narrow  conjugate,  while  the  occiput,  having  more  room, 
is  free  to  descend.  The  result  of  this  movenient  is  that  the 
bi-parietal  diameter  is  brought  into  the  wide  lateral  part  of 
the  brim,  while  the  bi-temporal 
diameter  engages  in  the  conju- 
gate. With  anterior  parietal  ob- 
liquity the  head  passes  through 
the  brim  by  a  movement  of  rota- 
tion round  the  'promontory  (Fig. 
220).  As  it  descends,  the  sagittal 
suture  approaches  th^  pubes, 
bringing  the  posterior  parietal 
bone  first  into  the  cavity  (Fig. 
220(2)).  Rotation  in  the  opposite 
direction  next  occurs,  the  sagittal 
suture  approaching  the  sacrum 
(Fig.  220  (3)  )  and  thus  bringing 
the  anterior  parietal  bone  into  the  cavity.  With  posterior 
parietal  obliquity  at  the  commencement  of  labour,  a  similar 
movement  of  rotation  round  the  pubes  occurs.  The  mecha- 
nical advantage  of  this  movement  of  rotation  is  indicated  in 


Fig.  221. — Wedge  Shape  of 
Foetal  Skull  on  Coronal 
Section.     (Dakin.) 

c — d.  Bi-parietal  diameter. 

h — a.  Super-sub-parictal  diameter. 


412 


ABNORMAL   LABOUR 


Fig.  221.  The  lateral  inclination  of  the  head  which  accom- 
panies this  movement  tilts  the  bi-parietal  plane  c — d,  and 
brings  into  the  brim  a  plane  the  diameter  of  which  is  indicated 
by  b — a.  This  is  the  super-sub-parietal  diameter,  measuring 
about  a  quarter  of  an  inch  less  than  the  bi-parietal.  The 
widest  part  of  the  head  thus  escapes  direct  engagement  in  the 
plane  of  the  brim.  Forward  rotation  of  the  occiput  will 
occur  if  the  head  is  flexed  when  it  reaches  the  pelvic  floor. 
When  the  head  has  passed  the  brim,  there  wiU  be  no  further 
difficulty  in  dehvery  unless  the  shoulders  are  dispropor- 
tionately large. 

If   the    movement    of    lateral   displacement    does    not 

occur,  as  labour  proceeds 
the  head  may  become 
completely  extended,  the 
posterior  part  being  pre- 
vented from  descending 
while  the  anterior  ^Dart 
has  sufficient  space  for 
this  movement.  This 
may  result  in  a  brow  or 
face  presentation. 

The  moulding  of  the 
foetal  head  is  modified  ; 
there  is  well-marked 
lateral  asymmetry,  the 
middle  of  the  posterior 
parietal  bone  being  much 
depressed  ;  but  in  the  longitudmal  plane  overriding  of  the 
bones  is  not  excessive  (Fig.  222).  Often  a  depression  or  a 
depressed  fracture  of  the  posterior  parietal  bone  is  caused 
by  the  pressure  exercised  upon  it  by  the  promontory 
(p.  643).  Or.  after  birth,  a  depression  may  be  found  upon  the 
posterior  parietal  bone,  which  marks  the  fine  of  compression 
by  the  promontory  in  the  movements  of  lateral  displacement 
and  rotation  round  the  sacrum. 

(6)  In  breech  presentation  the  mechanism  of  delivery  of 
the  after-coming  head  is  modified  as  follows  :  The  head 
engages  with  its  occipito -frontal  diameter  in  the  long  trans- 
verse diameter  of  the  brim  ;  a  movement  of  lateral  dis- 
placement, similar  to  that  just  described,  should  next  occur, 


Fig.  222. — Posterior  Aspect  of  Fcetal 
Skull :  Extreme  Moulding  from 
Labour  in  Plat  Pelvis.  (Ribemont- 
Dessaignes  and  Lepage.) 


PELVIC   CONTRACTION  413 

and  be  followed  by  a  movement  of  extension.  Owing  to  the 
wedge  shape  of  the  foetal  skuU  on  coronal  section  (Fig.  221), 
a  certain  mechanical  advantage  is  obtained  by  the  after- 
coming  head,  inasmuch  as  the  narrow  end  of  the  wedge — 
i.e.,  the  base  of  the  skull — first  enters  the  brim.  The  bi- 
parietal  diameter  will  therefore  tend  to  be  reduced  some- 
what by  compression  during  its  passage,  and  the  difficulty 
will  thus  be  diminished.  It  is  probable,  however,  that  this 
theoretical  advantage  is  nullified  by  the  fact  that  the  after- 
coming  head  is  not  subjected  to  the  process  of  moulding, 
which  in  a  contracted  pelvis  is  of  especial  importance^  by 
adapting  the  shape  of  the  head  to  the  distorted  canal  through 
which  it  has  to  pass.  Rotation  round  the  promontory, 
bringing  first  the  posterior,  and  then  the  anterior  parietal 
bone  into  the  pelvic  cavity,  will  occur  when  the  degree 
of  contraction  is  considerable. 

II.  Generally  contracted  Pelvis. — In  this  form  of  con- 
tracted pelvis  the  mechanism  of  labour  is  not  greatly 
modified,  as  the  proportions  of  the  pelvis  are  normal.  In 
head  presentation  the  movement  of  flexion  is  exaggerated, 
reducing  the  diameter  of  engagement  to  the  utmost  possible 
extent.  Internal  rotation  is  controlled  by  the  inclined 
planes  of  the  ischium,  not  by  the  pelvic  floor.  Upon  the  inner 
surface  of  the  ischium  a  shallow  ridge  may  be  traced  running 
from  the  ilio  pectineal  eminence  to  the  ischial  spine  ;  behind 
this  line  is  a  smooth  bony  surface,  the  posterior  ischial  plane  ; 
in  front  of  it  is  a  similar  surface,  the  anterior  ischial  plane 
(Fig.  107).  When  the  head  lies  in  the  oblique  diameter 
(first  position)  the  occiput  will  come  in  contact  with  the  left 
anterior  plane,  the  sinciput  with  the  posterior  plane  of  the 
opposite  side.  The  inclination  of  these  planes  is  such  that 
in  contact  with  the  anterior  plane  a  body  is  directed  forwards 
and  inwards  (towards  the  middle  line),  in  contact  with  the 
posterior,  backwards  and  inwards.  The  effect  will  therefore 
be  to  carry  the  head  from  the  oblique  into  the  antero- 
posterior, diameter.  Forward  rotation  of  the  occiput  will 
occur  in  the  first  and  second  positions,  backward  rotation 
in  the  third  and  fourth.  Unless  the  head  tightly  fits  the 
pelvis  this  effect  will  not  be  produced  ;  therefore  it  is  only 
in  the  case  of  a  generally  contracted  pelvis,  or  a  normal 
pelvis  with  an  abnormally  large  head,  that  it  can  be  looked 


414 


ABNORMAL   LABOUR 


for.  It  follows  that  backward  rotation  is  the  rule  in  occipito- 
posterior  positions  with  a  generally  contracted  pelvis  and 
a  head  of  average  size.  The  passage  of  the  head  through  the 
outlet  is  rendered  unusually  difficult  by  the  diminution  of 
the  antero-posterior  and  transverse  diameters  of  the  lower 
pelvic  strait.  In  this  respect  great  difference  exists  between 
the  flat  and  the  generally  contracted  pelvis. 

In  breech  presentation  also  the  mechanism  of  labour  is  not 
appreciably  modified,  but,  owing  to  the  reduction  in  length 
of  the  diameters  of  the  outlet,  displacement  of  the  arms  is 

very  frequent  and  the  dehvery  of 
the  after-coming  head  is  unusually 
difficult  ;  for  this  reason  breech  pre- 
sentation is  very  unfavourable  to 
the  foetus  in  a  generally  contracted 
pelvis.  If  extension  of  the  head 
should  occur  perforation  will  be  un- 
avoidable. 

The  moulding  of  the  head  is  of 
the  normal  type,  but  is  extreme  in 
degree  (Fig.  223)  ;  depression  and 
fracture  of  the  bones  are,  however, 
more  uncommon  than  in  a  fiat 
pelvis. 

Labour  is  more  difficult  in  a 
generally  contracted  pelvis  than  in 
a  flat  pelvis  with  an  equal  length  of 
conjugate,  for  the  reason  that  the 
former  is  contracted  throughout,  the 
In  the  flat  pelvis  all  difficulty  ceases 
when  the  head  has  passed  the  brim  ;  in  the  generally  con- 
tracted pelvis  the  deUvery  of  the  head  through  the  narrow 
outlet  is  the  most  difficult  stage. 


Pig.  223.— Extreme  Head 
Moulding  from  Labour 
in  generally  con- 
tracted Pelvis.  (Bar- 
bour.) 

latter  only  at  the  brim. 


Management  of  Labour  in  Contracted  Pelves 

The  size  of  the  pelvis  is  the  most  important  point  to  be 
considered  in  deciding  upon  the  method  of  obstetric  manage- 
ment to  be  applied  to  any  individual  case.  The  most  impor- 
tant diameter  to  be  considered  is  the  conjugate  of  the  brim, 


CONTRACTED   PELVIS  415 

and  it  is  convenient  to  arrange  cases  of  pelvic  contraction 
in  three  groups  according  to  the  length  of  this  diameter. 

A.  First  Degree  (C.V.  3|  to  4  inches). — It  must  in  the 
first  place  be  recognised  that  in  th's  degree  of  pelvic 
contraction  there  is  a  fair  prospect  that  delivery  at  term  may 
occur  either  naturally,  i.e.  spontaneously,  or  with  the  aid  of 
forceps.  The  chances  of  this  favourable  termination  are 
greatest  in  the  case  of  young  women  with  their  first  three  or 
four  labours  ;  in  a  primigravida  the  prospect  is  to  some 
extent  complicated  by  the  difficulties  usually  associated 
with  a  first  labour  ;  it  must,  however,  be  added  that  pelvic 
contraction  of  the  first  degree  frequently  goes  unrecognised 
in  a  first  pregnancy,  and  is  first  suspected  when  difficulty 
in  labour  occurs.  In  the  case  of  a  multipara  who  has  already 
had  many  children  the  prospect  is  also  less  favourable,  for 
in  such  women  the  uterus  has  lost  power,  and  is  accordingly 
unable  to  accomplish  that  effective  moulding  of  the  foetal 
head  which  is  required  if  it  is  to  pass  safely  through  the 
narrow  diameters  of  the  pelvis.  Unless  the  true  con- 
jugate diameter  measures  at  least  3 J  inches,  labour  at  term 
very  seldom  terminates  favourably,  although  occasional 
exceptions  in  which  a  foetus  of  average  size  has  passed 
through  a  narrower  pelvis  than  this  may  be  met  with.  In 
the  case  of  a  generally  contracted  pelvis  3f  inches  is  a  safer 
limit  to  adopt,  as  the  difficulties  are  greater  than  in  a  flat 
pelvis. 

The  reports  of  Queen  Charlotte's  Hospital  show  that 
during  the  seven  years  1905  to  1911  one  hundred  and  seventy- 
six  cases  of  pelvic  contraction  of  this  degree  were  delivered 
in  the  hospital  without  any  maternal  mortality,  although 
with  some  increase  of  the  rate  of  puerperal  morbidity  (see 
p.  545).  Labour  at  term  under  these  conditions  frequently 
requires  the  assistance  of  forceps,  for  in  one  hundred  and 
seven  cases  forceps  were  required,  as  compared  with  sixty- 
nine  cases  in  which  delivery  was  spontaneous.  The  foetal 
risks  are  not  serious  in  pelvic  contraction  when  delivery  is 
spontaneous  :  in  the  sixty-nine  cases  of  natural  delivery 
all  the  infants  survived  but  one,  which,  though  born  alive, 
succumbed  to  injuries  received  during  delivery,  i.e.  the 
foetal  mortality  was  1*4  per  cent.  But  among  the  one 
hundred  and  seven  cases  delivered  by  forceps,  in  seventeen 


416  ABNORMAL   LABOUR 

the  child  died  either  during  labour  or  the  first  few  days  of 
life,  giving  a  foetal  mortahty  for  this  method  of  delivery  of 
15-7  per  cent. 

From  these  considerations  it  is  evident  that  when  cases  of 
pelvic  contraction,  in  which  the  true  conjugate  is  at  least 
3|  inches,  are  allowed  to  go  to  term,  labour  requires  judicious 
management,  and  resort  should  not  be  made  to  the  use  of 
forceps  until  it  is  quite  evident  that  spontaneous  dehvery 
will  not  take  place.  Every  opportunity  should  be  given  to 
the  natural  forces,  by  moulduig  to  adapt  the  head  to  the 
abnormal  shape  and  size  of  the  canal  through  which  it  has 
to  pass.  There  are  two  requisites  for  this  process — viz.,  a 
strongly  and  regularly  acting  uterus,  and  a  prolonged  second 
stage.  Prolonged  mouldmg  by  the  natural  forces  involves 
much  less  injury  to  the  foetus  than  the  violence  done  by 
dragging  an  imperfectly  moulded  head  through  a  contracted 
pelvis. 

Li  all  such  cases  the  second  stage  of  labour  must  be 
closely  watched,  and  the  mechanism  studied  with  care.  In 
the  case  of  a  flat  pelvis  the  prognosis  is  considerably  affected 
by  the  kind  of  parietal  obhquity  which  is  present  ;  in  the 
anterior  variety  the  mechanism  appears  to  be  easier,  for  such 
cases  are  more  frequently  dehvered  spontaneously,  and  are 
more  favourable  for  forceps  extraction  than  the  posterior 
variety.  The  position  of  the  sagittal  suture  accordingly 
becomes  an  important  prognostic  indication  ;  if  this  suture 
is  found  posteriorly  when  the  head  is  detained  m  the  pelvic 
brim  the  prognosis  is  favourable.  The  overlapping  of  the 
bones  at  the  lines  of  suture  should  also  be  watched,  and  the 
more  marked  this  change  becomes,  the  better  the  prospect 
of  safe  delivery.  When  moulding  is  retarded  by  msufficiency 
of  the  contractions  or  by  rigidity  of  the  cranial  bones,  the 
passage  of  the  head  is  rendered  much  more  difficult.  In  a 
generally  contracted  pelvis  weU-marked  parietal  obliquity 
is  unusual ;  the  head  is  generally  weU  flexed,  bringing  the 
posterior  fontanelle  into  a  central  position  in  the  pelvis,  and 
this  point,  together  with  overlapping  of  the  bones  from 
mouldmg,  form  the  most  important  features. 

A  prolonged  second  stage  is  to  be  anticipated,  and  is 
indeed  requisite  for  a  successful  result.  In  all  cases  three  or 
four  hours  insij  be  allowed,  and  in  many  instances  this  may 


CONTRACTED   PELVIS  417 

be  considerably  exceeded  without  any  indication  of  '  fcetal 
distress  '  appearing.  Careful  observation  of  the  strength 
and  rate  of  the  foetal  heart  sounds  should  be  made  at  frequent 
intervals.  The  formation  of  a  large  caput  during  this  period 
is  to  be  anticipated,  and  is  not  a  sign  of  serious  importance. 
Attempts  to  deliver  the  head  by  the  high  forceps  operation 
(see  p.  699)  while  the  head  is  merely  engaged  or  but  imper- 
fectly moulded  are  strongly  to  be  deprecated  ;  serious  injury 
to  the  child's  head  is  almost  inevitably  caused  by  this  pro- 
cedure. When  it  is  evident  that  the  head  is  descending  and 
becoming  well  moulded,  and  there  are  no  signs  of  foetal 
distress,  the  use  of  forceps  should  be  withheld  as  long  as  the 
mother  can  be  encouraged  to  continue  her  efforts  and  there 
is  no  evidence  of  obstetric  exhaustion.  Should  the  advance 
of  the  head  cease  or  the  pains  become  ineffective,  forceps 
must  be  employed.  In  the  case  of  a  flat  pelvis,  when  the 
head  has  passed  through  the  brim,  forceps  need  no  longer  be 
v/ithheld,  as  delivery  through  the  cavity  and  outlet  will  be 
easy.  In  a  generally  contracted  pelvis  the  expulsion  of  the 
head  becomes  increasingly  difficult  as  the  outlet  is  reached, 
and  forceps  should  not  be  applied  till  the  head  has  reached  a 
lower  level. 

The  special  points  requiring  attention  in  forceps  delivery 
through  a  contracted  pelvis  will  be  referred  to  in  a  later 
section. 

B.  Second  Degree  (C.V.  3  to  3 J  inches). — When  the  con- 
jugate measures  3|  inches  or  upwards,  delivery  by  forceps 
can  usually  be  effected  when  labour  is  conducted  throughout 
in  the  manner  described  in  the  last  section.  In  the  case 
of  pelves  smaller  than  this  failure  with  forceps  is  not  uncom- 
mon, and  the  methods  of  delivery  which  may  be  practised 
after  forceps  has  failed  must  next  be  considered. 

If  the  child  is  dead  it  is  obvious  that  a  destructive  opera- 
tion may  suitably  be  performed  and  the  head  delivered  by 
craniotomy.  Care  must  be  exercised  in  deciding  that  death 
has  occurred,  for  mistakes  are  not  infrequently  made.  If 
the  foetal  heart  has  been  kept  under  observation  during  the 
second  stage  its  cessation  can  be  determined  without  hesita- 
tion ;  but  if  the  heart  has  not  previously  been  heard  by  the 
medical  attendant,  careful  and  repeated  observation  must 
be  made  before  deciding  that  the  heart-sounds  have  ceased. 
E.M.  ^7 


418  ABNORMAL   LABOUR 

Other  signs  of  foetal  distress  may  be  present  which  will  lend 
support  to  this  conclusion. 

If  the  child  is  stiU  alive  the  choice  of  the  method  of 
delivery  next  to  be  adopted  is  by  no  means  an  easy  one,  and 
somewhat  sharp  differences  are  to  be  met  mth  m  the  practice 
of  different  schools  of  midmfery.  The  alternatives  are 
dehvery  by  Ceesarean  section,  and  delivery  through  the 
natural  passages  by  the  aid  of  one  of  the  operations  designed 
temporarily  to  enlarge  the  pelvic  canal — viz.,  symphysiotomy 
and  pubiotomy  or  hebotomy.  These  procedures  will  be 
described  in  the  section  deahng  mth  obstetric  operations, 
and  their  relative  merits  cainiot  be  discussed  profitably  until 
the  methods  of  performing  them  have  been  considered.  It 
may,  however,  be  said  that  the  maternal  risk  is  not  appreci- 
ably greater  for  one  than  for  the  other,  and  the  chance 
of  the  ultimate  survival  of  the  child  is  better  with  Csesarean 
section  than  with  the  other  operation.  In  this  country 
dehvery  by  Csesarean  section  is  regarded  with  the  greater 
favour,  provided  that  there  is  reasonable  security  that 
the  uterus  has  not  been  infected.  When  the  conditions 
are  such  that  it  is  hkely  that  infection  has  occurred,  all 
operative  procedures  are  attended  with  serious  maternal 
risks,  and  craniotomy  must  be  considered  even  if  the  child 
is  ahve.  In  some  Contmental  chnics  and  in  Dublin  pubio- 
tomy is  preferred  to  either  Csesarean  section  or  symphysio- 
tomy. 

C.  Third  Degree  (C.V.  mider  3  inches). — Dehvery  of  a 
living  and  viable  child  is  impossible  through  a  pelvis  so 
small  as  this.  When  the  diagnosis  of  contraction  of  this 
degree  is  first  made  during  labour,  Csesarean  section  should 
be  performed  at  the  earhest  possible  moment.  If  labour 
has  ah'eady  been  prolonged  and  the  child  is  dead,  extraction 
by  craniotomy  can  be  performed  in  all  but  the  most  extreme 
cases  (see  p.  737). 

Prophylactic  Management. — Two  prophylactic  measures 
have  been  extensivel}^  practised  to  facihtate  dehvery  in 
cases  of  pelvic  contraction,  viz.,  (1)  prophylactic  podalic 
version,  and  (2)  induction  of  premature  labour. 

(1)  Podalic  version  by  the  external  or  combined  methods 
(see  p.  672)  has  been  practised  in  cases  oi  flat  pelvis  for  the 
theoretical  reasons  which  have  been  already  set  forth  in  con- 


CONTRACTED  PELVIS  419 

sidering  the  mechanism  of  delivery  of  the  after-coming 
head  (p.  376),  Experience  of  this  method  has,  however, 
shown  it  to  possess  one  great  disadvantage,  viz.,  that  the 
necessity  for  haste  in  delivering  the  after-coming  head 
renders  it  impossible  for  moulding  to  occur,  and  conse- 
quently considerable  force  may  be  required  to  extract  it, 
causing  serious  injury  to  the  head.  The  results  as  regards 
the  foetal  mortality  accordingly  compare  unfavourably  with 
those  obtained  by  delivery  with  forceps  in  the  manner 
described  above.  In  cases  of  flat  pelvis  it  is  better  that 
breech  presentations  should  be  corrected  before  labour,  as 
would  be  done  if  the  pelvis  were  of  normal  size.  Two 
advantages  are  gained  thereby,  viz.,  (1)  a  more  accurate 
determination  of  the  relative  sizes  of  the  foetus  and  the 
pelvis  can  be  obtained,  and  (2)  the  head  presentation  offers 
the  better  chance  of  delivering  a  living  child. 

In  cases  of  generally  contracted  pelvis  prophylactic 
podalic  version  should  never  be  performed. 

(2)  Induction  of  Premature  Labour. — The  object  of  in- 
ducing premature  labour  in  pelvic  contraction  is  to  avoid 
or  diminish  difficulty  by  arranging  that  labour  shall  come 
on  at  a  time  when  the  foetus  has  not  reached  its  full  develop- 
ment, and  accordingly  the  dimensions  of  the  head  are  less 
than  at  term.  This  procedure  is  not  attended  by  any 
aj)preciable  maternal  risk,  but  it  involves  the  serious  diffi- 
culty that  premature  infants  are  weakly  and  more  difficult 
to  rear,  and  often  require  skilled  attendance  for  a  long 
period  after  their  birth.  This  difficulty  is  naturally  more 
serious  among  the  poor  than  among  the  well-to-do  classes, 
but  as  the  great  majority  of  cases  of  pelvic  contraction  occur 
in  women  of  the  poorer  classes  the  difficulty  is  undoubtedly 
a  grave  one. 

Prophylactic  induction  must  therefore  stand  or  fall  by 
the  foetal  and  infantile  mortality  which  attends  it  ;  the 
procedure  cannot  be  considered  successful  unless  the  infant 
not  only  survives  its  birth,  but  subsequently  makes  such 
progress  as  would  give  it  a  fair  chance  of  life.  In  estimating 
the  foetal  mortality  of  prophylactic  induction,  all  cases  in 
which  the  infant  dies  during  the  first  fourteen  days  of  life 
must  be  included,  and  there  remains  some  doubt  as  to  the 
exact  proportion  of  infants  which,   being  discharged,   for 

27—3 


420  ABNORMAL   LABOUR 

instance,  from  a  lying-in  hospital  at  the  fourteenth  to  the 
twenty-first  day,  survive  the  first  year  of  life.  The  later 
mortahty,  inasmuch  as  it  could  be  very  largely  avoided  by 
proper  management,  is  not,  strictly  speaking,  to  be  regarded 
as  the  outcome  of  the  method  of  delivery. 

The  infant's  chance  of  survival  is  influenced  mainly  by 
two  factors — (a)  the  size  of  the  pelvis  through  which  it  has 
to  pass  ;  (6)  the  period  of  development  which  it  has  attained. 
To  a  great  extent  these  are  opposing  factors,  for  although  the 
smaller  the  foetus  the  more  easily  it  will  pass  through  the 
pelvis,  yet  the  smaller  the  foetus  the  less  chance  has  it  of 
surviving.  Experience  of  the  operation  shows  that  a 
premature  infant  of  4^  pounds  and  upwards  has  an  excellent 
chance  of  life  ;  this  weight  is  attained  under  normal  condi- 
tions at  about  the  thirty-sixth  week  (p.  57).  It  follows  that 
if  the  pelvis  is  large  enough  to  allow  a  child  of  this  size  to 
be  delivered  without  injury,  induction  of  premature  labour 
may  fairly  be  expected  to  be  successful.  Further  expe- 
rience has  sliown  that  unless  the  conjugate  diameter 
measures  at  least  S^  inches  (3|  inches  in  a  generally  con- 
tracted pelvis),  the  risk  of  injury  to  the  child  during  delivery 
is  so  great  as  to  contra-indicate  induction.  Therefore  it 
may  be  said  that  prophylactic  induction  is  most  likely 
to  be  successful  when  pregnancy  has  advanced  as  far  as 
the  thirty-sixth  week  and  the  conjugate  of  the  brim  measures 
at  least  3^  inches. 

In  the  case  of  a  pelvis  with  a  conjugate  definitely  exceed- 
ing 3|  inches  there  is  good  prospect  of  the  successful  delivery 
of  a  living  child  at  term.  Under  these  circumstances  labour 
need  not  be  induced  in  a  first  pregnancy,  but  if  there  is  a 
history  of  previous  difficulty  and  loss  of  the  child  during 
labour,  induction  may  be  practised. 

Having  decided  that  a  case  is  a  suitable  one,  as  regards 
the  size  of  the  pelvis,  for  treatment  by  prophylactic  induc- 
tion, the  selection  of  the  proper  time  for  interference  requires 
very  careful  consideration.  This  cannot  be  settled  by  definite 
rules,  for  while  a  fairly  correct  estimate  of  the  size  of  the 
pelvis  can  be  made  by  clinical  measurements,  this  is  not  the 
case  with  the  foetal  head.  The  size  of  the  foetus  at  a  given 
period  of  pregnancy  is  not  constant,  and  some  women 
habitually  bear  children  of  abnormally  large  size.     Accord- 


CONTRACTED   PELVIS 


421 


ingly  the  proper  time  for  induction  cannot  be  determined  by 
dates  and  pelvic  measurements  alone. 

In  every  case  it  will  clearly  be  of  advantage  to  the  child 
to  allow  pregnancy  to  continue  as  long  as  possible,  and  it 
therefore  becomes  necessary  to  form  an  estimate,  as  accurate 
as  possible,  of  the  relation  between  the  size  of  the  pelvis  and 
that  of  the  foetal  head.  Direct  measurements  of  the  head  in 
utero  cannot  be  made,  and  the  method  adopted  is  to  deter- 


FiG.  224.— The  Bi-manual  Method  of  EstiBaating  the  Eelative  Sizes  of 
the  Foetal  Head  and  the  Pelvic  Brim.     (Munro  Kerr.) 

mine  from  time  to  time  that  the  head  is  not  too  large  to  be 
pushed  down  into  the  brim  of  the  pelvis. 

This  estimation  may  be  made  by  the  external  or  the 
combined  method.  In  either  case  the  head  must,  of  course, 
be  presenting  ;  external  cephalic  version  must  therefore  be 
first  performed  if  the  presentation  is  abnormal.  In  stout 
women  it  is  difficult  to  get  a  satisfactory  result  even  under 
anaesthesia.  In  the  external  method  the  patient  lies  upon 
her  back  with  the  shoulders  slightly  raised  upon  pillows. 
The  head  is  then  located,  and  seized  by  the  two  hands  in  the 
'  first  pelvic  grip  '  described  on  p.  313.  Grasped  between 
the  two  hands  the  head  is  then  pushed  steadily  down  and 


422  ABNORMAL   LABOUR 

back  into  the  pelvis.  A  little  experience  is  required  to 
obtain  a  convincing  result,  and  the  procedure  is  much  more 
easily  carried  out  under  anaesthesia,  which,  however,  must 
be  pushed  to  the  point  of  complete  muscular  relaxation. 
The  combined  or  bi-manual  method  illustrated  in  Fig.  224 
is  that  of  Mliller  as  modified  by  Munro  Kerr  ;  this  also  can 
be  much  more  easily  carried  out  under  anaesthesia.  The 
patient  lies  at  the  edge  of  the  couch  in  the  modified  litho- 
tomy position,  the  legs  supported  by  assistants  or  in  a 
Clover's  crutch.  Two  fingers  of  the  left  hand  are  then 
passed  into  the  vagina  into  contact  with  the  head  at  the 
brim  ;  the  thumb  is  passed  in  front  of  the  pubes  so  as  to  feel 
the  upper  part  of  the  head  through  the  abdominal  wall. 
With  the  right  hand  the  head  is  then  pushed  down  mto  the 
pelvis,  its  descent  being  observed  by  the  fingers  and  thumb 
of  the  left  hand.  Pressure  upon  the  fundus  by  an  assistant 
is  sometimes  also  required.  It  is  thus  possible,  in  a  favour- 
able case,  to  determine  whether  the  greatest  diameter  of  the 
head  can  be  made  to  pass  into  the  brim. 

Another  method  of  estimating  the  relation  between  the 
size  of  the  head  and  that  of  the  pelvis  has  been  introduced 
recently  by  von  Herff.  He  measures  the  distance  between 
the  fifth  lumbar  spine  and  the  most  prominent  part 
anteriorly  of  the  child's  head.  If  this  is  equal  to  or  less 
than  the  external  conjugate,  the  head  will  enter  the  brim 
without  difficulty.  If  it  is  1  cm.  longer  than  the  external 
conjugate,  delivery  may  be  effected  spontaneously  with  the 
aid  of  Walcher's  position  (p.  711).  If  the  excess  is  3  cm. 
or  more,  the  case  will  present  very  considerable  difficulty. 

The  first  estimation  by  these  methods  should  be  made 
not  later  than  the  thirtj^-fourth  week.  If  it  is  found  that 
the  greatest  diameter  of  the  head  then  passes  easily  into  the 
pelvis  pregnancy  may  be  allowed  to  continue  for  another 
week,  when  the  manoeuvre  is  to  be  repeated.  As  soon  as 
difficulty  is  experienced  in  depressing  the  head  into  the 
brim  labour  should  be  induced.  A  certain  amount  of 
reduction  in  size  may  be  confidently  anticipated  from 
moulding  during  labour. 

Before  definitely  undertaking  induction  for  pelvic  con- 
traction, an  examination  under  anaesthesia  should  be  made, 
the    diagona,!    conjugate    being    carefully    measured,    and 


CONTRACTED   PELVIS  423 

estimation  made  by  the  combined  method  of  the  relative 
sizes  of  the  head  and  the  pelvis. 

Prophylactic  induction  is  extensively  practised  at  Queen 
Charlotte's  Hospital  under  the  conditions  described  above. 
In  10,000  labours  there  were  206  cases  of  induction  ;  among 
these  there  was  no  maternal  mortality,  but  26  of  the  infants 
did  not  survive  ;  the  remainder  all  left  the  Hospital  doing 
well  between  the  twelfth  and  twenty-eighth  days.  The 
maternal  mortality  was  therefore  nil,  the  combined  foetal 
and  infantile  mortality  12" 6  per  cent.  Von  Herff  has  recently 
published  statistics  from  the  University  Clinique  of  Basle 
which  show  a  foetal  and  infantile  mortality  of  20  per  cent., 
calculated  on  a.  series  of  120  consecutive  prophylactic  induc- 
tions, the  method  of  induction  employed  being  rupture  of 
the  membranes.  Under  carefully  selected  conditions  it  may 
therefore  be  considered  that  this  procedure  will  be  successful 
in  upwards  of  80  per  cent,  of  cases. 

A  premature,  induced  labour  is  to  be  conducted  on  the 
same  principles  as  those  laid  down  for  labour  at  term  in 
contracted  pelvis.  Instrumental  interference  should  not  be 
required  in  more  than  15  per  cent,  to  20  per  cent,  of  cases, 
and  forceps  delivery  should  never  be  resorted  to  at  an  early 
stage,  for  there  is  no  doubt  that  extraction  with  forceps  is 
more  likely  than  a  prolonged  second  stage  to  do  harm  to  the 
child. 

Rare  Forms  of  Contracted  Pelvis 

A.  Due  to  disease  affecting  the  skeleton  generally. 

(1)  Osteomalacic  pelvis. 

(2)  Pseudo-osteomalacic  pelvis. 

B.  Due  to  disease  of  the  pelvic  joints, 

(3)  NdgeWs  or  Oblique  pelvis. 

(4)  Robert's  or  Transversely  contracted  pelvis. 

(5)  Oblique  pelvis  due  to  disease  of  the  hip-joint. 

C.  Due  to  disease  of  the  vertebral  column. 

(6)  Funnel  pelvis  ;  Kyphotic  pelvis. 

(7)  Scoliotic  pelvis. 

(8)  Spondylolisthetic  pelvis. 

D.  Due  to  tumours  of  the  pelvic  bones. 

(1)  Osteomalacic  Pelvis  (Malacosteon  Pelvis,  Triradiate 


424 


ABNORMAL   LABOUR 


Fig.  225. — Osteomalacic  Pelvis  with  Moderate  Deformity. 

Pelvis). — Osteomalacia,  or  mollities  ossium,  produces  a 
characteristic  pelvic  deformity  shown  in  Figs.  225  and  22G. 
The  softening  produced  by  this  disease  weakens  the  pelvic 
bones  so  much  that  they  yield  to  pressure  in  all  directions, 
with  the  result  that  the  pelvis  collapses  and  entirely  loses 
its  shape.  The  lateral  pelvic  walls  fall  in,  this  change 
becoming  first  apparent  in  relation  to  the  anterior  part  of 
the  brim  in  front  of  the  acetabula  (Fig.  226).  This  produces 
the  characteristic  '  beaking  '  of  the  pubes.     As  the  deformity 


Fig.  226. — Osteomalacic  Pelvis :  Advanced  Deformity. 


CONTRACTED    PELVIS  425 

progresses  the  pelvic  walls  may  come  almost  in  contact  with 
one  another  in  their  anterior  parts.  The  sacrum  becomes 
displaced  forward,  the  spine  is  curved,  the  beaking  of  the 
pubic  bones  increases,  the  iliac  crests  become  twisted,  and 
extreme  deformity  results,  the  pelvic  brim  being  reduced  to  a 
triradiate  slit  (Fig.  226).  In  addition  to  the  changes  in  the 
pelvis,  marked  deformity  of  the  long  bones  and  of  the  verte- 


FiG.  227. — Pseudo-osteomalacic  Pelvis. 

bral  column  occurs.     Extreme  degrees  of  pelvic  contraction 
ar3  caused  by  this  disease. 

It  has  been  found  that  removal  of  the  ovaries  sometimes 
arrests  the  morbid  process  in  the  bones,  and  in  consequence 
Csesarean  section,  followed  by  removal  of  the  uterus  and 
ovaries,  has  been  advocated  as  the  best  treatment  during 
pregnancy.  Cure  of  existing  deformity  is  of  course  impos- 
sible, but  in  a  certain  proportion  of  cases  the  advance  of  the 
disease  has  been  arrested  by  this  operation.  Abortion  may 
be  induced  in  the  early  months  as  an  alterative  to  the 
radical  and  curative  operation. 


426 


ABNORMAL   LABOUR 


(2)  Pseudo-osteomalacic  Pelvis. — This  variety  is  due  to 
rickets,  and  has  received  its  name  from  the  resemblance 
it  presents  to  osteomalacic  contraction  (Fig.  227).  The 
pubic  bones  are  sUghtly  beaked,  but  the  lateral  pelvic  walls 
have  not  \delded  to  the  same  extent  as  in  the  former  variety. 
The  anterior  portions  of  the  ihac  crests  are  not  normally 
incurved,  so  that  the  interspinous  equals  or  exceeds  the 
intercristal  diameter  in  length.  Severe  rickets  is  the  cause 
of  the  deformity,  and  general  rachitic  changes  in  the  skeleton 
are  always  associated  with  it.     Treatment  in  pregnancy  is 


Fig.  228.— Xao-ele's  Pelvis 


governed  entirely  by  the  degree  of  contraction  present. 
The  recognition  of  this  and  the  foregoing  variety  is  facilitated 
by  the  obtrusive  signs  of  general  bone  disease  which  accom- 
pany them. 

(3)  Ndgele's  Pelvis. — This  variety  is  caused  by  disease 
occurring  in  infancy,  in  or  near  one  of  the  sacro-iliac 
synchondroses  ;  as  a  result  ankylosis  with  bony  union  of  the 
oint  occurs,  and  the  development  of  the  ala  of  the  sacrum  on 
the  affected  side  is  more  or  less  completely  arrested.  The 
resulting  deformity  is  shown  in  Fig.  228.  On  the  affected 
side  the  iho-pectineal  hne  is  almost  straight,  and  the  great 
sacro-sciatic  notch  is  much  narrower  than  its  fellow.     The 


CONTRACTED   PELVIS 


427 


symphysis  pubis  is  displaced  for  ^  inch  or  more  to  the 
sound  side  of  the  mesial  plane  of  the  body.  The  oblique 
diameter  of  the  sound  side  (the  right  in  Fig.  228)  is  con- 
siderably diminished  in  the  whole  pelvis  from-  brim  to 
outlet  ;  the  opposite  oblique,  the  transverse  and  antero- 
posterior diameters,  are  little  affected  ;  from  narrowing  of 
the  sacro-sciatic  notch,  the  sacro-cotyloid  diameter  (promon- 
tory to  back  of  acetabulum)  of  the  affected  side  is  very 
considerably  less  than  its  fellow.     The  distance  between 


Fig.  229.— Robert's  Pelvis. 


the  posterior  superior  iliac  spines  is  reduced,  and  the  pubic 
arch  is  asymmetrical. 

The  diagnosis  of  this  form  of  contracted  pelvis  is  difficult. 
The  patient  is  usually  well  developed,  and  may  show  no  sign 
of  lameness,  or  of  general  bone  disease.  The  oblique  and 
sacro-cotyloid  diameters  are  very  difficult  to  measure 
clinically,  and,  as  we  have  seen,  the  diameters  which  can  be 
estimated  are  not  greatly  affected.  The  flattening  of  the 
lateral  pelvic  wall  on  the  affected  side  can  be  recognised  by 
careful  digital  examination  under  anaesthesia,  and  the  lateral 
displacement  of  the  symphysis  pubis  is  a  valuable  indication 
of  the  condition.  An  x-ray  photograph  of  the  pelvis  is  the 
best  method  of  diagnosis.     Labour  will  be  difficult,  as  the 


428 


ABNORMAL  LABOUR 


diminution  in  the  area  of  the  j^elvic  brim  and  cavity  is 
considerable. 

(4)  Robert's  Pelvis. — This  form  of  pelvis  is  due  to  bi- 
lateral synostosis  of  the  sacro-iliac  synchondroses,  occurring 
in  infancy  ;  the  lesion  is  the  same  as  in  Xagele's  pelvis,  but 
it  affects  both  joints  (Fig.  229).  The  ala  of  the  sacrum  is 
imperfectly  developed  upon  both  sides  ;  both  iho-pectineal 
Hues  are  nearly  straight  ;  both  sacro-sciatic  notches  are 
diminished  in  width.  The  result  is  a  marked  diminution  in 
the  transverse  diameter  of  brim,  cavitv,  and  outlet  of  the 


Fig.  230.- — -Oblique  Pelvis  due  to  Congenital  Dislocation  of  Left 

Feniiu". 

pelvis  ;  the  pubic  arch  also  is  narrowed.  The  distance 
between  the  posterior  superior  iliac  spines  is  considerably 
reduced.  Diagnosis  is  easier  than  in  Nagele's  pelvis,  as  the 
transverse  diameters  of  the  brim  and  the  outlet  can  be 
more  readily  estimated  than  the  oblique. 

(5)  Oblique  Pelvis  due  to  disease  of  the  hip-joint. — Various 
forms  of  obhque  deformity  may  be  produced  by  subluxation 
of  the  hip  (which  may  be  uni-  or  bi-lateral,  congenital  or 
infantile)  and  by  caries  of  the  joint.  Spinal  curvature  is 
almost  always  associated  with  these  lesions.  The  resulting 
lameness  and  deformity  will  direct  attention  to  the  condition 


CONTRACTED   PELVIS 


429 


of  the  pelvis.  In  Fig.  230  it  will  be  seen  that  there  is  well- 
marked  tilting  of  the  pelvis,  and  the  flattening  of  the  lateral 
pelvic  wall  affects  the  sound  side,  reducing  the  length  of  the 
left  oblique  diameter. 

(6)  Funnel-shaped  Pelves. — In  this  form  the  important 
changes  are  found  at  the  pelvic  outlet,  which  is  contracted 
in  both  its  transverse  and  antero-posterior  diameters.  In 
consequence  of  the  transverse  contraction,  the  pubic  arch 
is  also  narrowed.  The  funnel  pelvis  has  recently  been 
carefully  studied  by  Whitridge  Williams,  who  found  that 


Fig.  231.— Kyphotic  Pelvis. 


in  Baltimore  this  form  of  contraction  is  fairly  frequent  ; 
he  measured  the  pelvic  outlet  in  2,215  consecutive  cases, 
and  found  it  contracted  in  135,  i.e.,  a  proportion  of  G'l  per 
cent.  There  are  no  similar  statistics  for  this  country,  and 
those  from  Continental  clinics  are  contradictory. 

Williams  describes  two  varieties  of  the  funnel  pelvis — 
the  simple  and  the  complex.  In  the  simple  funnel  pelvis 
the  measurements  of  the  false  pelvis  and  of  the  upper  pelvic 
strait  are  normal  ;  contraction  of  the  outlet  is  the  only 
change.  In  the  complex  variety  changes  occur  in  other 
parts  than  the  outlet  ;  thus  the  pelvis  may  be  generally 
contracted,  flat,  or  rachitic  ;   or  the  spine  may  show  angular 


430 


ABNORMAL   LABOUR 


curvature  due  to  old-standing  caries,  a  variety  of  funnel 
pelvis  to  which  the  name  of  kyphotic  is  usually  applied. 
Fairly  conclusive  evidence  has  been  adduced  that  the  simple 
funnel  pelvis  is  caused  by  lumbosacral  assimilation,  i.e., 


Fig.  232. — The  Sacrum  and  Lumbal'  Yertebrse  from  a  Case  of 
Spondylolistliesis.     (Xeugebauer . ) 


by  fusion  of  the  fifth  lumbar  and  first  sacral  vertebrae,  so 
that  the  sacrum  consists  of  six  pieces  instead  of  five. 

Diagnosis  of  contraction  of  the  outlet  may  be  made  by 
palpation  of  the  pubic  arch  and  measurement  of  the  trans- 
verse and  antero-posterior  diameters  in  the  manner  described 
on  p.  404.  When  the  transverse  diameter  is  as  low  as 
3j  inches  (8  cm.)  and  the  antero-posterior  diameter  as  low 
as  Z\  inches  (9  cm.)  a  diagnosis  of  funnel  pelvis  is  certain 
(Williams). 


CONTRACTED   PELVIS 


431 


Labour  is  not  affected  by  the  simple  funnel  pelvis  until 
the  head  reaches  the  pelvic  outlet,  when  an  insuperable 
obstacle  to  delivery  may  be  encountered,  if  the  degree  of 
contraction  is  considerable — transverse  diameter  below 
2 1  inches.  In  the  complex  varieties  labour  will  be  affected 
by  the  other  pelvic  changes.  If  forceps  fails  to  deliver 
the  head  through  a  contracted  outlet,  craniotomy  should 
be  performed  if  the  child  is  dead,  pubiotomy  if  it  is  alive. 
Williams  has  shown  that  the  latter  ojjeration  is  especially 
useful  under  these  conditions,  as  the  effect  upon  the  outlet 
of  division  of  the  pubic  bone 
is  very  marked.  Csesarean 
section  is  unsuitable  except 
in  the  rare  instances  in 
which  the  contraction  of 
the  outlet  may  have  been 
recognised  early  in  labour. 

(7)  Scoliotic  Pelvis. — 
Lateral  curvature  of  the 
spine  may  produce  a  cer- 
tain amount  of  asymmetry 
of  the  pelvis,  one  side  being 
somewhat  more  roomy  than 
the  other.  Only  slight 
degrees  of  pelvic  contrac- 
tion can,  however,  be  pro- 
duced in  this  way.  When 
associated  with  rickets,  sco- 
liosis may  produce  an  extreme  degree  of  oblique  deformity 
associated  with  flattening. 

(8)  Spondylolisthetic  Pelvis. — This  extremely  rare  form  of 
pelvic  contraction  is  due  to  forward  dislocation  from  caries  of 
the  body  of  the  fifth  lumbar  vertebra  (spondylohsthesis — 
aTr6vSv\o<;,  vertebra  ;  oXLO-drjac^,  gliding).  The  lumbar 
vertebrae  become  displaced,  descend  into  the  pelvis,  and  of 
course  greatly  diminish  the  available  length  of  the  conjugate 
diameter  (Fig.  232).  In  addition  the  pelvic  outlet  is  dimi- 
nished by  forward  displacement  of  the  lower  part  of  the 
sacrum  and  the  coccyx.  The  resulting  deformity  of  the  spine 
is  obvious,  and  on  vaginal  examination  the  displaced  lumbar 
vertebrae  can  be  recognised. 


Fig.  233. — Sacral  Exostosis. 
(Galabin.) 


432 


ABNORMAL  LABOUR 


(9)  Tumours    of    the    Pelvic    Bones. — Exostoses,    either 
single  or  multiple,  are  sometimes  found  in  the  pelvis,  the 


Malacosteon 


Naegele 

EiG.  234. — The  Outline  of  tlie  Pelvic  Brim  in  tlie  Principal 
Varieties  of  Contracted  Pelvis.     (Bumm.) 

commonest  positions  for  them  being  the  anterior  surface  of 
the  sacrum  (Fig.  223)  and  the  posterior  surface  of  the  pubes. 
In  the  latter  position  a  small  exostosis  which  has  been 
overlooked    may    cause    unexpected    difficulty    in    labour. 


OVARIAN   TUMOURS  433 

Cartilaginous  or  sarcomatous  growths  of  large  size  are  some- 
times met  with,  and  may  cause  insuperable  obstruction  to 
delivery. 


Abnormal  Conditions  of  the  Soft  Parts 

Ovarian  Tumours. — When  situated  entirely  above  the 
pelvic  brim,  these  tumours  do  not  give  rise  to  much  difficulty 
in  labour,  even  though  of  very  large  size.  They  may  occa- 
sion some  exaggeration  of  uterine  obliquity,  and  thus  lead 
to  abnormal  presentations  ;  but  in  this  situation  they  never 
cause  obstruction.  Axial  rotation  of  the  tumour,  leading  to 
serious  consequences,  may  occur  either  during  pregnancy  or 
in  the  puerperium.  The  diagnosis  of  a  large  ovarian  tumour 
in  the  abdomen  as  a  rule  is  not  difficult  during  labour  ;  the 
differential  diagnosis  of  hydramnios  has  been  already  referred 
to  (p.  160).  Operative  treatment  is  rarely  called  for  in 
labour,  and  should  be  postponed  until  the  patient  is  con- 
valescent, unless  acute  symptoms  arise  during  the  puer- 
perium. 

When  situated  wholly  or  partially  in  the  pelvic  cavity, 
ovarian  tumours  cause  serious  obstruction  in  labour  ;  they 
then  lie  below  the  presenting  part  and  prevent  the  descent  of 
the  foetus,  and  its  passage  through  the  outlet  (Figs.  45  and 
235).  Spontaneous  delivery,  although  very  rare,  may  occur 
in  the  following  ways  :  (1)  the  tumour,  if  cystic,  may  be 
ruptured  by  compression,  and  the  collapsed  cyst  may  then 
be  too  small  to  prevent  the  passage  of  the  foetus  ;  (2)  the 
tumour  may  rupture  the  pelvic  floor  and  be  expelled  in  front 
of  the  presenting  part,  either  through  the  anus  or  the  vulva ; 
in  such  cases  the  pedicle  of  the  tumour  may  be  torn  com- 
pletely across,  so  that  when  expelled,  the  tumour  is  entirely 
free  from  its  attachments.  If  the  obstruction  proves 
insuperable  and  is  not  artificially  relieved,  rupture  of  the 
uterus  will  occur. 

The  diagnosis  of  the  presence  of  a  pelvic  tumour  is  easy 
during  labour  ;  but  fibroid  and  ovarian  tumours  are  often 
mistaken  for  one  another,  for  under  continuous  pressure  a 
cystic  tumour  becomes  tense  and  its  walls  oedematous,  so 
that  its  consistence  appears  to  be  that  of  a  soft  solid  mass, 
while  fibroid  tumours  lose  their  naturally  hard  consistence 

E.M.  28 


434 


ABNORMAL   LABOUR 


during  pregnancy.  Unless  the  head  is  fixed  in  the  j)elvic 
brim  or  the  tumour  is  adherent  it  is  generally  possible,  under 
anaesthesia,  to  push  the  tumour  past  the  presenting  part 
above  the  pelvic  brim,  where  it  will  cause  no  further 
trouble  for  the  moment  ;  but  if  reposition  is  impossible 
from  adhesions,  or  from  any  other  cause,  the  best  treatment 
is  immediate  ovariotomy.  The  alternative  method  of  delivery 
by  forceps  or  craniotomy,  after  tapping  the  tumour,  is  not 


Cyst 


Os  externum 


Fig.  235.- 


-Ovarian  Cyst  obstructing  Labour  ;  Partial  Dilatation  of  the 
Cervix  has  occurred.     (Bumm.) 


to  be  generally  recommended,  for  so  much  injury  is  caused 
to  the  tumour  in  dragging  the  body  of  the  foetus  past  it  that 
peritonitis  from  bruising  and  rupture  frequently  ensue  in  the 
puerperium,  occasioning  a  high  maternal  mortality.  In 
exceptional  cases  it  may,  however,  be  the  safest  expedient 
to  adopt,  as,  for  instance,  when  the  unfavourable  surround- 
ings of  the  patient  render  the  performance  of  an  abdominal 
operation  unduly  dangerous.  In  such  cases  the  collapsed 
tumour  should  be  removed  within  two  or  three  days  after 
labour. 


FIBROID   TUMOURS  435 

Ovariotomy  during  labour  should  be  performed  by  the 
abdominal  route  ;  special  care  must  be  taken  in  securing 
the  vessels,  and  this  is  much  more  difficult  by  the  vaginal 
route.  If  the  tumour  is  adherent  in  the  pouch  of  Douglas 
it  may  be  necessary  to  make  a  very  long  incision,  and  turn 
the  uterus  out  of  the  abdomen  in  order  to  allow  room  to 
deal  with  the  tumour.  Or  the  child  may  first  be  delivered 
by  Csesarean  section  in  such  cases.  The  best  time  to  perform 
the  operation  is  towards  the  end  of  the  first  stage,  for  the 
cervix  being  dilated,  the  child  can  be  delivered  with  forceps 
by  an  assistant  as  soon  as  the  tumour  has  been  removed. 
If  performed  in  time,  the  prognosis  is  good  both  to  mother 
and  child,  although  ovariotomy  in  labour  is,  of  course, 
more  serious  than  in  pregnancy. 

Uterine  Tumours. — The  two  commonest  forms  of  uterine 
tumour — fibromyoma  in  the  body,  and  cancer  in  the  cervix 
— are  not  infrequently  encountered  in  connection  with 
pregnancy. 

The  influence  exerted  by  uterine  fibroids  upon  labour 
is  governed  almost  entirely  by  their  position.  Those  which 
occupy  the  lower  uterine  segment,  or  any  part  of  the  cervix, 
even  when  of  comparatively  small  size,  cause  serious  obstruc- 
tion to  delivery  ;  this  results  partly  from  their  bulk,  but 
mainly  from  the  fact  that  they  prevent  the  normal  dilatation 
of  these  parts  during  labour.  It  is  not  easy,  before  labour 
commences,  to  tell  whether  a  fibroid  tumour  situated  in  the 
lower  part  of  the  uterine  body  will  cause  obstruction  or  not, 
for  such  tumours,  when  they  do  not  encroach  upon  the  lower 
uterine  segment,  may,  by  the  action  of  the  uterus,  become 
drawn  up  into  the  pelvis  as  labour  proceeds,  so  as  not  to 
hinder  the  birth  of  the  child.  Fibroids  of  the  uterine  body 
which  are  interstitial  give  rise  to  mal-presentation  and 
irregular  uterine  action,  and  sometimes  cause  post-partum 
haemorrhage  by  interference  with  muscular  retraction.  Sub- 
peritoneal fibroids,  as  a  rule,  exert  no  effect  whatever  upon 
labour  ;  but  when  growing  from  the  lower  part  of  the 
posterior  uterine  wall  they  may  become  incarcerated  in  the 
pouch  of  Douglas,  and  give  rise  to  the  most  serious  obstruc- 
tion (Fig.  236).  Fibroids  in  any  position  are  liable  to  become 
infected  in  the  puerperium  if  the  sterility  of  the  uterine 
cavity    is    not    maintained.     A    uterus    which    contains    a 

28—2 


436 


ABNOR]\LA.L   LABOUR 


fibroid  tumour  is,  however,  not  more  likely  to  become 
infected  during  or  after  labour  than  one  which  does  not. 
Fibroids   are   also  Kable  to  undergo   certain  degenerative 


Sub -peritoneal  fibroids 
in  fundus 


Os  externum 


SvLb-peritonecil  fibroid 
in  pouch    of   Douglas 

Fig.  236. — Labour  otstnicted  by  a  Fibroid  Tumour;  Cervix  partlj- 
dilated.     (Bumm.) 

changes,  apart,  from  infection,  during  the  puerperium. 
Fibroid  polypi  have  no  influence  upon  labour,  but  may 
become  detached  and  expelled  during  labour  or  in  the 
puerperium . 


FIBROID   TUMOURS  43'7 

Treatment  turns  entirely  upon  the  question  of  obstruction. 
If  it  is  clear  that  there  will  be  insuperable  obstruction, 
the  best  treatment  is  to  allow  pregnancy  to  continue  and 
perform  Caesarean  section  at  or  near  term  (p.  721),  which 
may  be  followed  either  by  hysterectomy  (removal  of  the 
uterus)  or  myomectomy  (removal  of  the  fibroid).  It  can 
seldom  be  said,  however,  before  labour  that  insuperable 
obstruction  will  result,  except  in  the  case  of  interstitial 
cervical  fibroids,  and  sub-peritoneal  fibroids  which  have 
become  incarcerated  in  the  pouch  of  Douglas.  Fibroid 
tumours  situated  in  the  body  of  the  uterus  tend  in  all  cases 
to  become  displaced  upwards  as  pregnancy  advances  and 
the  growth  of  the  uterus  progresses.  In  this  way  a  tumour 
which  is  found  in  early  pregnancy  to  occupy  the  pouch  of 
Douglas,  in  a  position  likely  to  give  rise  to  serious  obstruc- 
tion, may  be  drawn  up  above  the  pelvic  brim  before  term 
is  reached.  In  its  new  position  obstruction  to  labour  is  not 
necessarily  caused  at  all,  and  natural  labour  may  be  awaited 
so  long  as  the  circumstances  permit  of  the  adoption  of 
suitable  operative  measures  should  difficulty  arise.  Labour 
in  a  fibroid  uterus  always  gives  rise  to  a  certain  amount  of 
anxiety,  but  the  actual  degree  of  difficulty  which  may  be 
met  with  is  not  easy  to  foretell.  The  Csesarean  operation, 
should  it  prove  necessary,  may  in  such  cases  be  performed 
with  perfect  safety  if  there  has  been  no  previous  interference. 
The  induction  of  abortion  for  an  obstructing  fibroid  tumour 
is  a  difficult  and  dangerous  operation,  for  it  may  prove 
impossible  to  secure  adequate  dilatation,  making  the 
evacuation  of  the  uterine  cavity  a  matter  of  extreme  diffi- 
culty.    In  consequence,  this  procedure  is  not  to  be  advised. 

Cancer  of  the  Cervix. — Advanced  cancer  of  thie  cervix  is  one 
of  the  most  serious  complications  of  labour  which  can  be  met 
with.  Owing  to  the  loss  of  the  normal  resilience  of  the 
tissues,  dilatation  is  impossible,  and  spontaneous  delivery 
can  only  occur  after  extensive  laceration.  The  puerperium 
may  then  terminate  fatally  from  infection  through  sloughing 
of  the  lacerated  tissues.  Treatment  consists  in  delivery  by 
Csesarean  section,  followed  by  supra-vaginal  amputation  of 
the  uterus  through  healthy  tissue  ;  when  the  child  is  dead 
it  may  be  delivered  by  craniotomy  if  sufficient  dilatation  can 
be  secured  to  render  this  practicable. 


438  ABNORMAL   LABOUR 

Early  cancer  of  the  cervix  often  does  not  prevent  delivery 
per  vias  naturales  ;  pan-hysterectomy  should  then  be  per- 
formed early  in  the  puerperium.  The  treatment  of  cancer 
of  the  cervix  in  pregnancy  has  been  referred  to  on  p.  217. 

Rigidity  of  the  Cervix. — The  term  '  rigidity,'  as  applied 
to  the  cervix  during  labour,  has  a  strictly  conventional 
significance,  and  may  be  understood  to  include  all  the  con- 
ditions in  which  dilatation  is  retarded.  In  one  class  of  cases 
the  cervical  tissues  are  to  all  appearances  healthy,  although 
dilatation  is  slow  or  incomplete  ;  this  condition  is  called 
functional  rigidity  of  the  cervix.  In  another  class  some 
morbid  condition  of  the  cervix  is  present,  to  which  the  fault 
may  be  attributed  ;    this  is  called  organic  rigidity. 

(1)  Functional  rigidity  is  met  with  in  primiparse  much 
more  frequently  than  in  multiparse.  It  may  arise  from 
irregular  or  weak  uterine  contractions  in  the  first  stage  of 
labour  {^primary  inertia)  ;  from  premature  rupture  of  the 
membranes  resulting  in  loss  of  the  natural  cervical  dilator — 
the  bag  of  waters  ;  from  morbid  adhesion  of  the  membranes 
in  the  lower  uterine  segment,  preventing  the  formation  of 
the  bag  of  waters  ;  from  an  unusual  density  of  the  cervical 
tissues,  met  with,  as  is  believed,  in  elderly  primiparse  (over 
thirty  years)  ;  from  oedema  of  the  cervical  tissues  induced  by 
compression  when  the  pelvis  is  contracted,  or  when  in  a 
normal  pelvis  the  vertex  is  extended  ;  and  possibly,  in  the 
last  place,  from  spasmodic  contraction  of  muscular  fibres 
in  the  cervix.  It  will  be  seen  that  some  of  these  conditions 
are  in  reality  abnormalities  in  the  mechanism  of  dilatation. 

The  clinical  result  of  functional  rigidity  of  the  cervix  is 
prolongation  of  the  first  stage  of  labour,  which  may  be 
delayed  for  many  hours  or  even  for  a  day  or  two.  The 
mother  is  then,  naturally,  greatly  fatigued,  but  in  other 
respects  the  maternal  consequences  are  not  serious. 

As  long  as  the  membranes  remain  unruptured  there  is 
little  risk  to  the  foetus.  Clinically  speaking,  cases  may  be 
divided  into  two  groups  :  those  in  which  the  pains  are  weak, 
and  those  in  which  the  pains  are  strong.  In  the  former 
primary  uterine  inertia  (see  p.  443)  is  also  present,  and  is  an 
important  factor  in  causing  the  difficulty  in  dilatation  ;  in 
the  latter  the  uterine  action  is  normal. 

Treatment  depends  in  the  main  upon  the  cause.     If  the 


CERVICAL   RIGIDITY  439 

action  of  the  uterus  is  at  fault,  the  treatment  is  that  of 
primary  uterine  inertia.  On  the  other  hand,  if  the  pains 
are  strong,  repeated  inhalations  of  chloroform  sufficient 
to  produce  only  slight  anaesthesia,  and  the  administration  of 
chloral  or  bromide  in  repeated  small  doses,  are  useful 
remedies.  But  the  most  useful  of  all  is  the  hypodermic 
injection  of  scopolamine  and  morphine,  as  described  on 
p.  444.  In  the  spasmodic  variety,  it  is  said  that  local  appli- 
cation to  the  cervix  of  a  10  per  cent,  solution  of  cocaine  is 
useful,  but  the  recognition  of  this  variety  is  difficult.  If  these 
means  are  unsuccessful,  dilatation  must  be  assisted,  and  as 
this  involves  very  little  risk  to  the  mother  it  should  not  be 
postponed  until  she  is  tired  out.  If  the  external  os  is  about 
two-thirds  dilated  and  the  head  presents,  the  patient  should 
be  anaesthetised,  dilatation  completed  by  the  fingers,  and 
forceps  at  once  applied.  In  a  breech  presentation  a  leg 
should  be  pulled  down.  If,  however,  the  cervix  is  less  than 
two-thirds  dilated,  a  de  Ribes'  bag  should  be  introduced  : 
this  will  dilate  the  cervix  in  an  hour  or  two  and  delivery  can 
then  be  effected. 

(2)  Organic  rigidity  of  the  cervix  may  be  due  to  adhesion 
of  the  lips  of  the  os  externum  to  one  another,  to  small  size  of 
the  OS  externum  {pin-hole  os),  to  hypertrophic  elongation  of 
the  cervix,  to  cicatrices,  or  to  the  presence  of  a  small  cystic 
or  solid  cervical  tumour.  Fibroid  and  malignant  cervical 
tumours,  already  considered,  may  also  be  regarded  as  causes 
of  organic  rigidity.  Small  size  of  the  os  externum  in  a 
primipara  sometimes  leads  to  a  curious  form  of  partial 
dilatation  of  the  cervix,  in  which  the  whole  of  the  cervical 
canal  becomes  fully  opened  up  except  the  os  externum  itself. 
The  head  descends  low  into  the  vagina,  the  wall  of  the  cervix 
is  tightly  stretched  over  it,  and  may  be  mistaken  for  the 
unruptured  bag  of  waters  if  the  small  aperture  representing 
the  OS,  and  situated  upon  the  lowest  part  of  the  bulging 
swelling,  should  be  overlooked.  If  in  such  a  case  the 
uterine  pains  are  strong,  transverse  rupture  of  the  anterior 
wall  of  the  cervix  may  occur  (Fig.  237).  Small  tumours 
should  be  dealt  with  by  removal ;  the  other  conditions 
may  be  treated  either  by  incision  or  by  some  method  of 
artificial  dilatation.  Incision  is  probably  the  best  treatment 
for  all  but  hypertrophic  elongation,  which  must  be  dealt 


440 


ABNORMAL  LABOUR 


with  by  artificial  dilatation.  In  performing  this  small 
operation  an  anaesthetic  will  not  be  required  unless  the 
patient  is  unusually  nervous  ;  a  Sims  speculum  should  be 
passed  to  expose  the  cervix,  and  with  scalpel  or  scissors  two 
deep  incisions  should  be  made  through  the  cervical  tissues 
at  the  sides  of  the  os,  one  passing  backwards  and  to  the 
left,  the  other  backwards  and  to  the  right.     An  interval  of 


Edge  of  the  cervii-al 
laceration. 


Fig.  23 T. — Transverse  Laceration  of  the  Anterior  Cervical  Wall  and  Non- 
dilatation  of  the  Os  Externum.  (Diagrammatic  from  a  case  at 
Queen  Charlotte's  Hospital.) 

an  hour  or  two  should  be  allowed  in  order  to  see  if  the  uterine 
contractions  will  now  complete  the  dilatation  naturally.  If 
this  does  not  occur  the  dilatation  should  be  completed  with 
the  fingers,  under  anaesthesia,  and  forceps  applied.  If 
cicatrices  are  present,  the  incisions  should  be  made  through 
the  cicatricial  tissue,  and  dilatation  should  then  be  allowed  to 
proceed  naturally.  The  same  methods  of  artificial  dilata- 
tion may  be  employed  as  in  the  case  of  functional  rigidity. 


PERINEAL   RIGIDITY 


441 


Rigidity  of  the  Pelvic  Floor. — In  elderly  primiparge  (over 
thirty)  the  perineal  body  and  the  other  tissues  composing 
the  pelvic  floor  appear  to  be  deficient  in  elasticity,  and 
consequently  dilatation  of  the  vulva  at  the  end  of  the  second 
stage  does  not  proceed  normally.  The  head  may  therefore 
be  delayed  for  a  long  time  uj^on  the  pelvic  floor,  slightly 
distending  the  vulva  with  each  pain,  but  unable  to  escape  ; 


Pig.  238. — Episiotomy  in  a  Face  Presentation.     (Edgar.) 

unless  the  uterine  contractions  are  unusually  powerful, 
forceps  will  be  required  to  extract  it.  On  the  other  hand, 
if  the  uterine  action  is  violent,  the  head  will  be  driven  by 
great  force  through  the  undilated  vulva,  causing  a  serious 
perineal  laceration.  Occasionally  in  such  cases  the  vulva 
does  not  dilate  at  all,  and  a  laceration  then  occurs  in  the 
perineal  body  between  the  fourchette  and  the  anus,  through 
which  the  head  and  body  of  the  child  escape.  This  is  termed 
central  or  intra-perineal  rupture.     It  is  not  always  mesial  in 


442  ABNORMAL   LABOUR 

position,  and  the  latter  term  is  therefore  preferable.  Atten- 
tion must  be  paid  in  all  such  cases  to  the  proper  management 
of  expulsion,  and  time  allowed  for  the  perineum  to  stretch. 
If  a  tear  apjoears  to  be  inevitable,  two  lateral  incisions  may 
be  made  in  the  anterior  edge  of  the  perineum  (episiotomy)  ; 
when  tearing  occurs  it  will  then  follow  the  lines  of  these 
incisions  and  be  dkected  backwards  and  outwards  away 
from  the  rectum,  thus  avoiding  the  risk  of  laceratmg  the 
sj)hincter  ani  (Fig.  238). 

Abnormalities  in  the  Action  of  the  Uterus 

Precipitate  Labour. — Cases  are  occasionally  met  with  in 
which  labour  proceeds  so  raj^idly  as  to  disturb  the  normal 
mechanism,  the  stages  of  dilatation  and  expulsion  occurring 
simultaneously,  or  being  mdistinguishable  from  one  another. 
After  only  two  or  three  violent  pains  have  been  felt  the  child 
may  suddenly  be  expelled,  and  be  followed  immediately  by 
the  after-bh'th  ;  the  whole  process  thus  apparently  occupying 
only  a  few  mmutes.  It  is  difficult,  however,  in  such  cases  to 
elimmate  an  element  of  uncertamty — viz.  the  possibility  that 
uterine  contractions,  painless  but  effective,  have  been  m 
progress  unobserved  by  the  j)atient,  and  have  effected  the 
usual  dilatation  ;  the  violent  pains  which  suddenly  ensue 
thus  representing  only  a  precipitate  second  stage.  The 
conditions  which  lead  to  precipitate  labour  are  excessive 
force  of  the  uterine  contractions,  and  diminished  resistances 
in  the  pelvis.  Nothing  is  known  of  the  causes  of  the  former  ; 
but  as  instances  of  the  latter  may  be  mentioned  the  justo- 
major  pelvis,  and  the  relaxed  or  lacerated  condition  of  the 
cervix  and  pelvic  floor,  often  met  with  m  multiparse. 

Precipitate  labour  is  unfavourable  both  to  the  mother 
and  the  child.  Rapid  exhaustion  of  the  uterus  leading  to 
post-partum  haemorrhage  may  occur,  or  the  process  of 
uterme  inversion  maj'  be  set  up  (see  p.  480)  ;  also  serious 
lacerations  of  the  cervix  and  perineum  may  occur  in  primi- 
parse,  and  in  consequence  there  is  increased  risk  of  sepsis. 
Owing  to  the  fact  that  the  j)atient  is  taken  unawares, 
deliver}^  may  occur  in  the  erect  position  and  the  child  may 
be  killed  by  a  fall  on  the  floor,  if  the  cord  gives  way  under 
the  strain.     Manv  instances  have  occurred  where  it  has  been 


UTERINE    INERTIA  443 

expelled  into  the  water-closet.  Of  800  cases  of  precipitate 
labour  collated  by  Bayer,  it  was  found  that  in  only  15"5per 
cent,  was  the  patient  delivered  while  lying  down.  The  oppor- 
tunity of  treating  such  cases  will  seldom  arise  ;  uterine 
action  should  be  retarded  as  much  as  possible  by  the  free 
administration  of  chloroform. 

Uterine  Inertia. — Two  varieties  of  uterine  inertia  are 
described,  primary  and  secondary  ;  these  are  really  distinct 
conditions  which  have  nothing  in  common,  but  it  is  con- 
venient to  retain  the  names  by  which  they  are  usually 
known. 

(1)  Primary  inertia  is  a  condition  in  which  the  uterine 
contractions  are  ineffective,  the  resistances  being  normal — 
i.e.,  the  foetus  and  pelvis  are  of  normal  size,  and  there  is  no 
cause  of  obstruction.  The  first  and  second  stages  are  greatly 
prolonged,  and  assistance  in  delivery  is  frequently  required  ; 
the  third  stage  is,  however,  in  all  respects  normal,  therefore 
the  function  of  retraction  is  adequate,  although  that  of  con- 
traction is  not.  The  contractions  may  be  either  feeble  or 
partial,  or  both  feeble  and  partial  ;  the  intervals  are  usually 
irregular  and  prolonged.  Sometimes  the  patient  complains 
of  almost  continuous  severe  pain,  but  on  palpation  only 
feeble,  and  often  partial,  uterine  contractions  can  be  felt, 
yet  these  contractions  may  appear  to  cause  much  more 
severe  pain  than  the  effective  contractions  of  a  normal 
labour. 

It  is  met  with  more  commonly  in  primiparae  than  in 
multiparas,  and  is  not  associated  with  errors  of  general  health 
or  development.  Sometimes  a  disturbance  of  the  normal 
mechanism  of  labour,  such  as  over-distension  of  the  uterus 
(hydramnios,  twins),  ante-partum  rupture  of  the  mem- 
branes, or  mal-presentation,  appears  to  induce  primary 
inertia.  Frequently,  however,  no  such  cause  can  be  dis- 
covered, and  the  condition  has  then  been  referred  to  defective 
innervation  of  the  uterus,  reflex  disturbance  of  the  action  of 
the  lumbar  centre,  degeneration  of  the  uterine  muscle,  &c. 
Evacuation  of  the  bladder  or  rectum,  when  these  viscera  are 
full  or  over-full,  often  produces  a  favourable  influence,  and 
it  is  fair  to  conclude  that  such  conditions  may  reflexly  dis- 
turb uterine  contractions.  Nothing  is  definitely  known  of 
any  form  of  degeneration  of  the  uterine  muscle  which  may 


444  ABNORMAL   LABOUR 

cause  primary  inertia.  Unusual  nervousness  on  the  part  of 
the  patient  is  often  observed,  and  may  possibly  in  some  way 
disturb  the  normal  innervation  of  the  process. 

The  results  of  primary  inertia  are,  as  a  rule,  not  serious 
either  to  mother  or  child.  If  the  mother  is  allowed  to  remain 
in  constant  pain  and  without  sleep  for  twenty-four  hours  or 
longer,  she  T\ill  become  greatly  exhausted,  and  such  cases 
have  been  known  to  terminate  fatally.  As  long  as  the 
membranes  remain  intact  the  foetus  will  not  suffer. 

Treatment. — The  management  of  a  labour  complicated  by 
primarj^  inertia  greatly  taxes  the  strength  and  patience  of  the 
mother,  and,  it  may  be  added,  of  the  doctor  and  the  nurse 
also.  The  general  indication  must  be  said  to  be  to  postpone 
operative  mterference  as  long  as  possible  ;  the  temptation 
to  expedite  matters  by  some  operative  method  must  be 
resisted  until  time  has  been  allowed  for  the  natural  forces  to 
advance  the  course  of  labour  as  far  as  they  can.  Then  comes 
the  moment  at  which  interference  is  proper  and  desirable. 

During  the  prolonged  first  stage,  what  the  patient  suffers 
from  most  is  fatigue  and  want  of  sleep.  Sedatives  must 
therefore  be  administered.  Chloral  hydrate,  bromides,  or 
morphia,  unless  administered  in  large  doses,  do  not  exert 
sufficient  influence  upon  the  uterine  contractions  to  allow  of 
sleep  ;  if  they  are  given  in  sufficient  doses  to  produce  sleep 
they  arrest  the  progress  of  labour.  The  best  remedy  is  a 
combination  of  scopolamme  (hyoscme)  and  morphia,  in  the 
dose  of  100  grain  of  the  former  and  |  or  |  grain  of  the  latter, 
given  hypodermically,  A  great  many  chnical  observations 
have  now  been  made  with  this  remedy  in  labour,  and  its 
safety  and  usefulness  may  be  considered  as  satisfactorily 
established.  It  has  been  administered  freely  both  in  normal 
and  in  protracted  labour.  The  effect  is  to  make  the  patient 
drowsy  so  that  she  sleeps  almost  continuously  between  the 
pams,  waking  up  whenever  the  contractions  recur.  The 
pains  themselves,  so  far  from  bemg  retarded,  often  gam  in 
strength  and  regularity,  although  the  intervals  between 
them  may  be  unusually  long.  If  one  dose  does  not  produce 
a  marked  effect,  it  may  be  repeated  after  an  hour  to  two 
hours  have  elapsed.  Sleep  once  induced  may  be  maintained 
by  doses  of  wo  gram  of  scopolamine,  the  morphine  being 
added  to  every  third  or  fourth  dose.     It  is  quite  possible  by 


UTERINE   INERTIA  445 

the  use  of  these  drugs  to  keep  the  patient  in  a  condition  of 
narcotic  '  sleep  '  throughout  the  whole  course  of  labour  ; 
she  is  then  unconscious  of  pain  throughout,  and  wakes  up 
to  find  the  child  born  and  the  labour  ended.  In  certain 
Continental  clinics  this  has  been  practised  over  a  large 
series  of  normal  and  abnormal  cases  without  maternal 
mishap.  Constant  medical  supervision  is,  however,  requisite, 
and  accordingly  it  is  unsuitable  for  the  conditions  which 
prevail  when  women  are  confined  in  their  own  homes,  as 
is  usually  the  case  in  this  country.  The  effect  of  these 
narcotics  in  assisting  dilatation  of  the  cervix  is  very  marked, 
but  on  account  of  the  long  intervals  between  the  pains, 
progress  is  slow.  If  forceps  are  required,  light  chloroform 
anaesthesia  must  be  super-added.  In  the  second  stage  they 
must  be  used  with  caution,  and  only  when  it  is  clear  that 
progress  is  very  slow  and  it  is  desired  to  postpone  instru- 
mental interference,  as  in  cases  of  pelvic  contraction  (see 
p.  416).  A  distinct  but  not  dangerous  soporific  influence  is 
often  manifest  in  the  child  when  born,  but  this  seldom 
reaches  a  degree  in  which  it  interferes  with  the  establish- 
ment of  the  respiratory  function.  It  is,  of  course,  inad- 
missible to  administer  hyoscine  and  morphia  to  a  woman 
suffering  from  cardiac  or  pulmonary  disease. 

If  these  remedies  fail,  some  artificial  method  of  aiding 
dilatation  will  be  required  ;  if  the  cervix  is  less  than  two- 
thirds  dilated  the  use  of  de  Ribes'  bag  is  probably  the  best 
method  ;  if  two-thirds  dilated  or  more,  and  the  pelvis  is  of 
normal  size,  dilatation  may  be  completed  with  the  fingers 
under  anaesthesia,  and  the  forceps  at  once  applied.  Digital 
dilatation  of  the  cervix  is  an  operation  by  no  means  devoid 
of  risk  (see  p.  670) ;  it  should  not  be  lightly  undertaken,  and 
in  performing  it  great  care  and  strict  antiseptic  precautions 
are  required.  When  used  merely  to  complete  the  natural  pro- 
cess of  dilatation  there  is  not  much  risk  of  serious  injury. 

Many  attempts  have  been  made  to  excite  stronger  and 
more  efficient  contractions  by  stimulation  of  the  uterus,  but 
these  are  all  unreliable,  and  need  not  be  described.  It 
should  not  be  forgotten  that  a  distended  bladder  or  a  loaded 
rectum  often  exert  a  very  unfavourable  influence  upon 
uterine  contractions,  and  the  conditionrf)f  these  organs  must 
not  be  overlooked. 


446  ABNORMAL   LABOUR 

The  second  stage,  if  allowed  to  proceed  without  inter- 
ference, will  also  be  very  protracted.  But  it  is  not  necessary 
to  await  the  expulsion  of  the  child  by  the  natural  efforts,  if 
the  presentation  is  a  vertex  and  no  cause  of  obstruction 
exists  ;  labour  may  then  be  terminated  by  forceps  as  soon 
as  dilatation  of  the  cervix  is  complete.  With  a  breech 
presentation  delay  may  be  desirable  in  the  interests  of  the 
child. 

(2)  Secondary  inertia  is  in  reahty  exhaustion  of  the 
uterus  ;  it  is  marked  by  a  complete  cessation  of  uterine 
action,  bringing  the  process  of  labour  to  a  standstill  ;  the 
functions  of  contraction  and  retraction  are  both  in  abeyance  ; 
in  this  important  respect  it  differs  essentially  from  primary 
inertia.  The  labour  usually  commences  normally  with 
satisfactory  or  even  unusually  vigorous  pains,  but  they  soon 
die  away,  either  rapidly  or  gradually  ;  in  other  words,  the 
uterus  is  capable  of  actmg  normally  at  first,  but  cannot 
maintain  its  action  for  a  sufficient  time  to  terminate  labour. 
It  may  occur  at  any  stage  of  labour — rarely  in  the  first,  more 
frequently  in  the  second  and  third  ;  it  may  also  supervene 
suddenly  when  labour  is  entirely  over,  resulting  in  the  com- 
plete loss  of  the  power  of  retraction.  It  occurs  mainly  m 
multiparse,  and  is  found  especially  m  those  who  have  had 
a  rapid  succession  of  pregnancies  ;  there  is  no  doubt  that  it 
depends  upon  some  defect,  either  in  structure  or  in  innerva- 
tion, of  the  uterine  muscle  ;  the  nature  of  this  defect  is, 
however,  unlaio\^ai.  No  harm,  either  to  mother  or  child, 
follows  its  occurrence  during  the  second  stage,  for  the  head 
may  remam  for  many  hours  m  the  pelvis,  when  both  are  of 
normal  size,  without  injurious  effects.  After  a  more  or  less 
prolonged  interval  the  pains  usually  return  and  labour 
termmates  naturally.  When  uiertia  occurs  after  the 
expulsion  of  the  child,  serious  haemorrhage  results,  omng  to 
the  fact  that  the  exhausted  uterus  is  unable  to  retract. 

The  treatment  during  the  first  or  second  stage  is  to  procure 
sleep  by  the  administration  of  morphia  or  chloral.  After  a 
period  of  sleejD,  uterine  pains  wiU  probably  recur  spon- 
taneously, and  labour  should  then  be  terminated  as  rapidly 
as  possible,  or  the  uterus  will  again  become  exhausted.  The 
temptation  to  deliv^er  with  forceps  m  the  total  absence  of 
uterine  contractions  must  always  be  resisted.     It  is  a  cardinal 


UTERINE   INERTIA  447 

rule  of  obstetrics  that  delivery  should  never  be  effected  by 
artificial  means  in  secondary  inertia,  for  the  most  serious  and 
uncontrollable  post-partum  haemorrhage  may  result  from  a 
breach  of  this  rule.  The  treatment  of  secondary  inertia  in 
the  third  stage  and  after  labour  is  considered  on  p.  518. 

Minor  degrees  of  secondary  inertia  may  be  successfully 
treated  by  drugs  during  the  second  stage.  The  most  useful 
are  pituitary  extract,  the  effect  of  which  in  stimulating  the 
uterine  muscle  has  been  already  alluded  to,  and  ergot. 

Pituitary  Extract. — Extended  experience  of  this  remedy 
has  shown  it  to  be  of  great  value  in  obstetrics.  It  is  un- 
doubtedly the  most  potent  drug  we  possess  for  stimulating 
the  activity  of  the  uterine  muscle.  It  has  comparatively 
httle  effect  on  the  inactive  uterus,  but  upon  the  parturient 
uterus  its  effects  are  very  marked.  Its  action  is  temporary 
only,  and  lasts  on  an  average  from  one  to  two  hours.  It  is 
very  important  to  use  a  reliable  preparation,  such  as  that 
sold  under  the  name  of  '■  pituitrin." 

It  should  not,  as  a  rule,  be  given  during  the  first  stage  of 
labour,  for  the  reasons  :  {a)  that  a  rigid  cervix  may  be 
ruptured  by  sudden  powerful  contraction  of  the  uterus  ; 
(6)  that  there  is  some  risk  of  foetal  asphyxia  from  interference 
with  the  placental  circulation  ;  this  action  is  more  dangerous 
in  the  first  than  in  the  second  stage,  when  delivery  can  be  at 
once  effected  if  the  signs  of  foetal  distress  are  observed. 
During  the  second  stage,  whenever  causes  of  obstruction  can 
be  excluded,  pituitrin  is  of  great  value  ;  if  the  uterus  is  acting 
well  its  use  is  unnecessary  ;  but  in  cases  of  inertia,  complete 
or  partial,  its  effect  is  well  seen,  and  by  its  use  a  forceps 
operation  may  be  frequently  avoided.  In  a  multipara  the 
effect  of  a  single  dose  is  often  to  effect  delivery  within  a 
quarter  of  an  hour. 

In  the  third  stage  or  after  labour  it  may  be  given  as  an 
alternative  to  ergot  for  the  purpose  of  ensuring  complete 
uterine  retraction. 

The  dose  is  1  c.c.  of  "pituitrin,"  or  1  c.c.  of  a  20  per 
cent,  solution  of  pituitary  extract  ;  the  injection  should  be 
made  deeply  into  the  muscles  of  the  buttock  or  thigh.  A 
second  dose  may  be  given  in  an  hour  if  the  effect  of  the 
first  is  inadequate. 

Ergot  may  also  be  made  use  of  in  similar  circumstances, 


448  ABNORMAL   LABOUR 

but  its  effect  is  less  certain  and  less  decided  than  that  of 
pituitary  extract. 

The  Action  and  Uses  of  Ergot. — In  small  doses  ergot  acts 
as  a  general  haemostatic,  contracting  the  calibre  of  the 
peripheral  blood-vessels  ;  this  action  is  made  use  of  in  cases 
of  slight  bleeding  from  the  uterus  during  pregnancy.  In 
larger  doses  it  exerts  a  specific  effect  upon  the  uterine  muscle 
when  in  action.  This  effect  is  to  increase  the  force,  duration, 
and  frequency  of  the  uterine  contractions  and  to  stimulate 
retraction.  In  still  larger  doses  the  effect  is  intensified  and 
the  whole  uterine  muscle  passes  into  a  condition  of  tetanic 
contraction.  Ergot  is  unable,  in  any  dose,  to  transform  the 
contractions  characteristic  of  pregnancy  into  those  charac- 
teristic of  labour  ;  therefore  it  is  useless  for  inducing  abortion 
or  premature  labour,  and  its  specific  effect  is  manifested 
only  upon  the  parturient  uterus.  It  is  believed  that  ergot 
acts  upon  muscle  by  stimulating  the  peripheral  nerve 
terminations. 

It  is  found,  clinically,  that  the  action  of  ergot  upon  the 
parturient  uterus  is  somewhat  variable  and  uncertain,  and 
this  appears  to  be  due  to  the  difficulty  of  making  efficient 
pharmaceutical  preparations  of  the  drug.  Accordingly  the 
effect  is  difficult  to  control,  and  there  is  some  risk  of  pro- 
ducing tetanic  contraction  by  its  use  except  in  small  quantity. 
It  is,  as  a  rule,  withheld  until  after  the  expulsion  of  the  after- 
birth for  fear  of  inducing  tetanic  contraction  in  the  third 
stage  (see  p.  517)  ;  it  may,  however,  be  administered 
towards  the  end  of  the  second  stage  to  stimulate  the  uterus 
and  as  a  preventive  of  third  stage  or  post-partum  inertia 
under  certain  well-defined  conditions  as  follows  :  if  the  pre- 
sentation is  a  vertex,  the  patient  a  multipara,  and  no  con- 
dition likely  to  cause  obstruction  to,  or  delay  in,  delivery 
is  present.  Under  these  conditions  it  may  be  given  in 
secondary  inertia,  or  after  prolonged  chloroform  anaesthesia. 
After  the  termination  of  the  third  stage,  it  is  useful  in  multi- 
parse,  in  maintaining  uterine  contraction  and  promoting  the 
expulsion  of  blood-clot  from  the  uterus.  Primiparse  do  not, 
as  a  rule,  require  it  after  labour,  and  it  should  seldom  be 
given  to  them  during  the  second  stage,  lest  serious  lacera- 
tion of  the  pelvic  floor  should  occur  from  too  hasty  exj)ul- 
sion  of  the  child. 


TONIC   CONTRACTION  449 

Over-action  of  the  Uterine  Muscle. — This  condition  is 
the  opposite  of  inertia  ;  both  the  functions  of  contraction 
and  retraction  are,  or  may  be,  exaggerated  as  the  result  of 
excessive  stimulation.  Three  varieties  of  this  condition  are 
to  be  described  : — 

(1)  Excessive  uterine  retraction,  leading  to  over-disten- 

sion of  the  lower  uterine  segment  and  formation  of 
an  exaggerated  retraction  ring. 

(2)  General  tonic  contraction  of  the  uterus. 

(3)  Local  tonic  contraction  of  the  uterus  leading  to  a 

contraction  ring. 

(1)  Excessive  retraction  may  be  considered  first  as  being 
the  simplest  of  the  three  varieties.  It  results  from 
mechanical  obstruction  to  delivery,  in  consequence  of  which 
the  upper  active  part  of  the  uterus  makes  violent  efforts 
to  overcome  the  obstacle.  Retraction  of  the  upper  part 
gradually  attains  an  extreme  degree,  while  the  lower  passive 
part  simultaneously  becomes  attenuated.  Consequently  the 
level  of  the  transition  from  active  to  passive  parts  is  marked 
by  an  abrupt  change  in  thickness  of  the  wall,  forming  an 
unusually  well-marked  "  retraction  ring."  It  is  therefore 
an  exaggeration  of  the  normal  action  of  the  parturient 
uterus,  and  is  seen  in  cases  of  obstructed  labour,  representing 
an  attempt  to  overcome  some  serious  mechanical  obstacle  to 
delivery.     It  will  be  further  referred  to  in  a  later  section. 

(2)  General  Tonic  Contraction. — This  condition,  on  the 
other  hand,  represents,  not  an  exaggeration  of  normal 
function,  but  a  perversion  of  function  of  the  uterus.  The 
physiological  differentiation  of  the  uterine  body  into  an 
upper  active  and  a  lower  passive  portion  (lower  uterine 
segment)  is  lost,  and  pronounced  retraction  occurs  in  the 
whole  of  the  uterus,  with  the  exception  of  the  part  below  the 
internal  os.  In  an  extreme  case  intermittent  contractions 
cease,  and  the  whole  organ  passes  into  a  condition  of  tonic 
muscular  spasm  or  tetanus. 

It  results  from  irritation  or  over-excitation  of  the  uterus 
during  labour,  and  only  very  powerful  stimuli,  in  operation 
for  a  long  time,  can  cause  it.  Thus  it  may  occur  during 
labour  from  three  main  caused  :  (1)  from  the  unsuccessful 
efforts  of  a  powerfully  contracting  uterus  to  overcome 
obstruction  ;  (2)  from  the  irritation  caused  by  repeated 
E.M.  29 


450  ABNORMAL   LABOUR 

unsuccessful  attempts  at  artificial  delivery  ;  (3)  from  inju- 
dicious administration  of  ergot.  In  the  worst  instances,  the 
two  first-named  causes  are  both  present.  It  involves  the 
most  serious  risks  to  the  mother  and  child. 

Complete  tonic  contraction  is  characterised  clinically  by 
severe  and  continuous  pain,  leading  after  a  time  to  rise  of 
temperature  and  quickening  of  pulse.  The  Hquor  amnii  is 
completely  expelled,  the  placenta  becomes  compressed 
against  the  body  of  the  foetus,  and  the  latter  wiU  consequently 
in  a  short  time  perish  from  asphyxia.  Intermittent  contrac- 
tions have  ceased,  and  on  abdommal  examination  the  uterus 
wiU  be  found  to  be  smaU,  tender  to  the  touch  and  con- 
tinuously hard,  so  as  entirely  to  obscure  the  outlines  of  the 
foetus  on  palpation.  As  the  foetus  is  dead,  the  heart-sounds 
have  ceased.  On  vaginal  examination  the  presenting  part 
will  be  found  immovable  and  covered  with  a  vevj  large 
caput  succedaneum  ;  if  the  condition  has  persisted  for  some 
time  the  vaginal  and  vulval  mucous  membranes  will  be  found 
swollen,  dry,  and  tender.  Cases  so  severe  as  this  are  seldom 
met  with  except  where  repeated  unsuccessful  attempts  at 
delivery  by  version  or  forceps  have  been  made,  the  irritation 
caused  by  the  repeated  introduction  of  the  hand  or  the  instru- 
ment into  the  uterus  bemg  the  dkect  cause  of  the  tetanus. 
If  unrelieved,  rupture  of  the  uterus  may  occur. 

The  diagnosis  of  general  tonic  contraction  presents  no 
difficulty  ;  it  is  impossible,  with  ordinary  care,  to  mistake  it 
for  secondary  inertia,  a  condition  in  which  pains  are  absent 
and  the  uterus  is  relaxed. 

The  treatment  of  both  forms  of  tonic  contraction  is  the 
same  {vide  infra). 

(3)  Local  Tonic  Contraction. — In  this  condition  an 
aimular  area  of  the  uterine  waU  passes  into  tonic  contrac- 
tian,  while  the  parts  above  and  below  it  continue  to  play 
their  normal  j^hysiological  part.  In  other  words,  the  upper 
part  contracts  intermittently,  while  the  lower  part  is  relaxed. 
The  consequence  is  that  a  narrowing  of  the  lumen  of  the 
uterus  occurs  at  the  affected  part,  the  constriction  being  of  a 
dense  and  highly  resistant  character  (Fig.  239).  This  annular 
constriction  may  be  termed  f he  contraction  ring,  to  distin- 
guish it  from  the  retraction  ring  already  described  in  connec- 
tion with  the  physiology  of  normal  labour.     The  contraction 


TONIC   CONTRACTION 


451 


ring  is  always  situated  in  the  lower  part  of  the  body  of  the 
uterus,  and  apparently  above  the  level  of  the  internal  os. 
It  is  largely  owing  to  the  recent  work  of  British  obstetricians 
that  this  form  of  tonic  contraction  has  been  recognised  and 


Placenta    ^-,, 


Cervix 


Fig.  239. — Local  Tonic  Contraction  of  the  Uterus. 
(Clifford  White.) 


understood.  The  causation  of  this  variety  is  similar  to  that 
of  general  tonic  contraction,  but  may  be  regarded  as  the 
response  to  a  less  powerful  irritation  Cases  have  been 
recorded  in  premature  rupture  of  the  nembranes  in  which 
no  obstetric  interference  had  been  piactised  ;  after  intra- 
uterine manipulation  ;    after  mal-presentation,  uncorrected 

29—2 


452  ABNORMAL   LABOUR 

for  a  long  time  ;  and  after  uterine  infection  during  labour. 
In  the  great  majority  of  cases  the  ring  has  been  observed 
during  the  second  stage  of  labour  ;  in  some  instances  during 
the  third  stage,  when  it  obstructs  delivery  of  the  placenta  : 
one  case  has  been  observed  in  which  it  formed  during  the 
first  stage,  the  membranes  being  intact.  When  occurring 
in  the  third  stage  it  gives  rise  to  the  condition  known  as 
'  hour-glass  contraction  '  (p.  513). 

The  effect  of  the  contraction  ring  is  completely  to  obstruct 
the  further  advance  of  the  foetus.  As  a  rule  the  ring  is 
found  to  be  jfirmly  moulded  upon  some  relatively  small 
part  of  the  foetal  body,  such  as  the  neck  in  head  presentation, 
or  a  hmb  in  shoulder  and  breech  presentations.  In  a  few 
cases  it  has  formed  altogether  below  the  presenting  part, 
the  entrance  of  which  into  the  brim  has  thus  been  effectually 
prevented.  In  either  case  labour  is  brought  to  a  standstill, 
and  further  progress  is  impossible  untU  the  condition  has 
been  relieved. 

The  diagnosis  of  the  contraction  ring  is  made  by  finding 
the  constriction  on  vaginal  examination.  The  general  con- 
dition of  the  patient,  as  a  rule,  remains  good,  temperature 
and  pulse  being  normal ;  in  this  respect  the  distinction  from 
general  tonic-  contraction  is  well  marked.  On  abdominal 
examination  the  greater  part  of  the  uterus  still  shows 
intermittent  contraction,  and  during  the  intervals  of 
relaxation  the  position  and  parts  of  the  foetus  can  be  made 
out.  The  presence  of  the  ring  is  not  recognisable,  as  a  rule, 
on  abdominal  examination.  On  vaginal  examination  the 
condition  will  escape  notice  unless  the  fingers  are  passed 
well  up  above  the  presenting  part,  except  in  the  rare  instances 
in  which  the  ring  forms  below  it.  Examination  under 
anaesthesia  to  discover  the  cause  of  the  delay  in  labour  will 
permit  of  palpation  being  effectually  carried  out.  Care  must 
be  exercised  in  attempting  to  pass  the  fingers  through  the 
ring,  as  rupture  of  the  uterine  wall  may  easily  be  caused. 

The  treatment  of  both  varieties  of  tonic  contraction  may 
now  be  considered. 

(a)  General  Tonic  Contraction. — This  condition  offers  the 
greatest  difficulty  to  delivery  by  the  natural  passages. 
The  child  is  invariably  dead,  and  treatment  can  therefore 
be  regulated  entirely  by  the  maternal  interests.     Owing  to 


TONIC  CONTRACTION  453 

the  non-differentiation  of  the  uterus  into  active  and  passive 
portions,  the  muscular  spasm  tends  not  to  expel  the  foetus, 
but  to  hold  it  tightly  in  position.  This  effect  has  been 
aptly  designated  by  Eardley  Holland  "  active  retention  of 
the  foetus."  This  force,  which  is  very  powerful,  must  be 
overcome  before  the  child  can  be  extracted. 

Many  attempts  to  cause  relaxation  of  the  muscular 
spasm  have  been  made,  but  with  constant  ill-success. 
Full  doses  of  morphia  aided  by  chloroform  ansesthesia  fail 
as  a  rule,  and  owing  to  the  serious  constitutional  symptoms 
which  are  present  a  long  delay  is  contra-indicated.  Opera- 
tive measures  must,  therefore,  be  adopted  in  almost  all  cases. 
The  most  suitable  method  is  embryotomy,  but  the  conditions 
do  not  always  permit  of  this  being  effectually  carried  out. 
If  the  head  presents  it  should  be  perforated  and  crushed  by 
the  cephalotribe  ;  traction  should  then  be  applied  to  the 
instrument  carefully  and  continuously,  without  the  exercise 
of  undue  force.  While  traction  is  being  applied  delivery  of 
the  trunk  may  be  assisted  by  division  of  the  clavicles 
(cleidotomy)  to  diminish  the  width  of  the  shoulders.  In 
presentation  of  the  breech  or  shoulder  embryotomy  may  be 
very  difficult  to  carry  out,  and  Csesarean  section  is  the  only 
alternative,  followed  by  removal  of  the  uterus  if  signs  of 
uterine  infection  are  also  present. 

{b)  The  Contraction  Ring  is  to  be  treated  upon  the  same 
general  principles.  The  general  condition  of  the  mother 
being  usually  good  there  is  not  the  same  urgency,  and  more 
time  may  be  expended  in  efforts  to  deliver.  Narcotics, 
even  when  combined  with  ansesthesia,  have  little  effect 
upon  the  spasm.  The  child  is  in  almost  all  cases  dead,  and 
there  is,  therefore,  no  objection  to  embryotomy  ;  owing  to 
the  localisation  of  the  obstructing  ring,  this  operation  is  also 
easier  to  carry  out.  When  the  child  is  dead  and  the  head 
presents,  craniotomy  should  be  performed  before  attempting 
extraction,  for  even  in  skilled  hands  forceps  delivery  may 
result  in  serious  rupture  of  the  uterus, 

Ante-partum  Rupture  of  the  Membranes. — When  intra- 
uterine tension  is  considerably  increased  during  the  latter 
weeks  of  pregnancy,  as  in  twins  or  hydramnios,  or  when 
from  unusual  opening  up  of  the  cervix  before  labour  the 
lower  pole  of  the  ovum  is  unsupported,  or  when  from  any 


454  ABNORMAL   LABOUR 

cause  the  chorion  and  amnion  are  unusually  weak,  rupture 
of  the  bag  of  waters  may  occur  before  labour  has  begun. 
This  is  known  as  ante-partum  or  premature  rupture  of  the 
membranes.  It  is  met  with  chiefly  in  connection  with 
hydramnios  or  multiple  pregnancy,  conditions  which  fre- 
quently occur  together.  The  immediate  result  is  the  escape 
of  liquor  amnii  ;  this  usually  occurs  slowly,  but  large  quan- 
tities may  be  gradually  discharged,  the  flow  being  usually 
intermittent,  and  corresponding  with  the  involuntary  uterine 
contractions.  Ultimately  labour  supervenes  ;  but  several 
days  may  elapse  before  this  occurs,  and  even  intervals 
of  several  weeks  are  not  very  uncommon.  If  the  fluid  is 
in  considerable  excess,  no  harm  will  follow  from  the  escape 
for  several  days,  for  sufficient  will  remain  in  the  uterus  to 
protect  the  foetus  from  injurious  pressure. 

With  regard  to  diagnosis  one  point  only  requires  mention 
— viz.,  that  after  ante-partum  rupture  of  the  membranes  and 
escape  of  a  good  deal  of  fluid  the  examining  finger  may  still 
detect  the  presence  of  a  small  lax  bag  of  waters  below  the 
presenting  part.  This  may  be  explained  by  the  fact  that  in 
such  cases  the  point  of  rupture  is  not  the  lower  pole  of  the 
membranes,  but  some  point  higher  up,  the  fluid  escaping  from 
the  amniotic  sac  and  finding  its  way  between  the  chorion  and^ 
the  uterine  wall  into  the  vagina.  Again,  in  rare  cases,  small 
quantities  of  fluid  may  be  present  between  the  chorion  and 
the  amnion,  which  may  escape  by  rupture  of  the  chorion,  the 
amnion  remaining  intact.  In  this  case  also  a  bag  of  waters 
will  be  found,  but  the  quantity  of  fluid  lost  in  this  way  is 
always  small. 

The  course  of  labour  is  usually  unfavourably  influenced 
both  as  regards  the  mother  and  the  child.  Owing  to  the 
absence  of  the  natural  cervical  dilator — the  bag  of  waters — 
the  flrst  stage  is  prolonged  and  made  difficult.  But  if  a  fair- 
sized  bag  should  remain,  this  difficulty  will  be  in  great  part 
obviated.  From  the  co-incident  over-distension  of  the  uterus 
primary  inertia  is  frequently  met  with.  Infection  of  the 
amniotic  cavity  by  pathogenic  organisms,  from  a  morbid 
vaginal  secretion,  or  introduced  from  without  by  examina- 
tion, may  occur.  In  some  such  cases  the  liquor  amnii 
becomes  offensive,  but  this  is  not  invariably  the  case  ;  fever 
and  other  signs  of  sepsis  may  form  the  earliest  indication  that 


OBSTRUCTED   LABOUR  455 

intra-uterine  infection  has  occurred.  The  foetus  invariably 
perishes  under  such  circumstances,  either  during  or  soon  after 
labour.  Further  dangers  to  the  child  are  that  the  cord  or  a 
limb  may  prolapse,  or  that  the  uterus  may  close  down  upon  it 
when  all  the  liquor  amnii  has  escaped,  and  by  compression  of 
the  placenta  lead  to  death  from  asphyxia. 

Management. — When  rupture  of  the  membranes  occurs 
before  labour,  interference  is  not  immediately  indicated,  for 
there  is  no  danger  to  the  child  until  the  whole  of  the  liquor 
amnii  has  drained  away.  In  many  cases  labour  will  ensue 
spontaneously  within  a  day  or  two,  although  much  longer 
intervals  often  elapse.  The  patient  should  be  kept  in  bed, 
or  at  least  lying  down,  and  careful  examination  should  be 
made  daily  to  determine  (1)  the  amount  of  liquor  amnii 
which  remains  in  the  uterus  ;  (2)  the  condition  of  the  foetal 
heart-sounds  ;  (3)  the  absence  of  signs  of  infection.  The 
degree  of  mobility  of  the  foetus  and  the  girth  of  the  abdomen 
are  the  best  guides  to  the  amount  of  fluid  present  ;  while  the 
heart-rate  remains  between  120  and  140  no  harm  from  com- 
pression need  be  feared,  but  a  steady  or  continuous  rise  or 
fall  of  the  rate,  above  or  below  this  level,  forms  an  important 
danger-signal. 

It  is  best  to  induce  labour  in  two  or  three  days,  even  if 
there  are  no  signs  of  foetal  distress  ;  but  this  should  be  done 
at  once  if  evidence  either  of  foetal  compression  or  of  uterine 
infection  is  obtained  earlier  than  this.  The  best  method  to 
employ  is  the  introduction  of  the  de  Ribes  bag  ;  this  instru- 
ment not  only  dilates  the  cervix  and  excites  uterine  pains, 
but  also  prevents  further  escape  of  liquor  amnii  by  plugging 
the  lower  segment  and  cervix.  The  cervix  is  usually 
sufflciently  dilated  to  admit  the  dilator  in  these  cases,  but 
if  not  it  must  be  previously  stretched  to  the  required  size 
(seeT)r663). 

Obstructed  Labour 

This  term  may  be  conveniently  applied  to  cases  in  which 
spontaneous  delivery  through  the  natural  passages  is  impossible. 
A  considerable  number  of  different  conditions,  which  may  be 
tabulated  as  follows,  may  cause  obstruction  in  labour, 
although  all  of  them  do  not  invariably  produce  that  result  -. 


456  ABNORMAL   LABOUR 

I.  Maternal  Conditions. 

Pelvic  contraction. 
Tumours  of  the  pehac  bones. 
Ovarian  and  uterine  tumours. 
Undilatable  atresia  of  the  cervix  or  vagina. 

II.  Foetal  Conditions. 

Brow  presentation. 

Face  presentation  with  backward  rotation  of  the 

chin. 
Transverse  presentation. 
Locked  twdns. 

Certain  developmental  anomalies  : 
(a)  Hydrocephalus. 
(6)  Gigantism  or  post-maturity. 
(c)  Abdominal  tumours  or  ascites. 
(e)  Spina  bifida. 
(/)  Double  monsters. 
The    maternal    conditions    and    the    mal-presentations 
named   in   this   list   have   been   already   considered.     The 
remaining  foetal  conditions  may  be  briefly  referred  to  before 
considering  the   clinical  results   of   obstructed  labour.     It 
will  be  observed  that  while  in  hydrocephalus  the  difficulty 
will  be  to  deliver  the  head,  in  the  conditions  named  after  it, 
the  difficulty  will  be  in  delivering  the  trunk. 

Hydrocephalus. — This  condition  consists  in  an  enlarge- 
ment of  the  head  due  to  an  accumulation  of  fluid  ;  in  the 
great  majority  of  cases  this  accumulation  occurs  in  the 
cerebral  ventricles  (hydrocephalus  internus),  in  others  it 
occurs  in  the  sub-arachnoid  space  (hydrocephalus  externus). 
The  amount  of  fluid  present,  and  the  consequent  enlarge- 
ment of  the  head,  ranges  widely  in  different  cases.  A 
case  has  been  recorded  by  Anton  m  which  the  cubic  capacity 
of  the  skull  was  found  to  be  8,300  cc.  (14|  pints)  ;  amounts 
of  from  two  to  three  pints  have  frequently  been  withdrawn 
from  the  head  after  puncture  or  perforation  during  labour. 
It  is  obvious  that  a  degree  of  obstruction  sufficient  to 
cause  serious  difficulty  in  labour  would  result  from  the 
presence  of  a  much  smaller  amount  of  fluid  than  this, 
and  as  a  hj^drocephalus  of  moderate  size  is  more  difficult  to 
recognise  before  birth,  such  cases  often  give  rise  to  more 
trouble  than  those  of  the  largest  size. 


HYDROCEPHALUS  457 

The  hydrocephalic  head  is  globular  in  shape,  the  brow 
protuberant,  the  face  of  relatively  very  small  size  ;  the 
cranial  bones  are  poorly  ossified,  as  a  rule,  thin  and  sometimes 
crepitant  on  pressure  ;  the  sutures  and  fontanelles  very 
wide.  Occasionally  a  hydrocephalic  head  is  found  fully 
ossified.  Other  deformities  are  not  uncommonly  associated, 
such  as  spina  bifida,  meningocele  or  encephalocele,  club  foot, 
etc.  The  amount  of  brain  substance  present  varies  with 
the  degree  of  fiuid  accumulation  ;  in  bad  cases  it  exists 
only  in  the  form  of  a  thin  shell  enclosing  the  fluid,  and 
there  is  no  distinction  to  be  perceived  between  the  grey 
and  the  white  matter.  The  cerebellum  and  the  cranial 
nerves  are  often  unaffected.  Minor  degrees  of  hydrocephalus 
are  not  incompatible  with  the  development  of  a  normal  or 
even  of  an  unusually  high  intelligence. 

The  cause  of  hydrocephalus  is  unknown.  Hereditary 
syphilis  is  regarded  as  a  predisposing  factor,  and  there  is  no 
doubt  that  hydrocephalus  occurs  with  uncommon  frequency 
among  syphilitic  foetuses.  The  occasional  occurrence  of  a 
series  of  cases  in  the  same  family  has  been  observed,  and  if 
in  such  instances  syphilis  has  been  excluded,  it  suggests 
that  heredity  may  be  an  important  causal  factor.  Many 
authorities  believe  that  pre-natal  meningitis  is  the  actual 
precursor  of  the  excessive  formation  of  fluid,  the  ependyma 
of  the  lateral  ventricles  being  the  parts  chiefly  affected  ; 
such  changes  can  be  frequently  demonstrated  after  birth. 
Meningitis  may  be  the  result  of  a  syphilitic  paternal 
taint. 

During  'pregnancy  hydrocephalus  gives  rise  to  no  com- 
plications, as  a  rule,  and  is  accordingly  seldom  recognised. 
During  labour  it  may  give  rise  to  obstruction  of  the  most 
serious  kind  resulting  in  rupture  of  the  uterus.  In  109 
cases  of  labour  with  hydrocephalus  recently  collated  (Hohl, 
Schuchard  and  Veit),  twenty  deaths  occurred  from  uterine 
rupture.  The  difficulty  of  diagnosis  during  labour  accounts 
for  this  heavy  maternal  mortality.  Breech  presentation  is 
more  common  than  in  normal  cases,  but  the  majority  present 
by  the  head.  Owing  to  the  soft  consistence  of  the  markedly 
hydrocephalic  head  the  condition  is  by  no  means  easy  to 
recognise  on  abdominal  examination,  especially  if  the  breech 
presents.      Vaginal  examination,  with  the  head  presenting 


458  ABNORMAL   LABOUR 

may  reveal  very  wide  sutures  and  fontanelles,  with  thin 
crepitant  bones,  but  the  latter  sign  occurring  alone  has  no 
diagnostic  significance  as  it  may  be  met  with  when  the  head 
is  of  normal  size.  Owing  to  the  fact  that  the  head  is  too 
large  to  enter  the  brim  of  the  pelvis,  palpation  of  the  sutures 
is  practically  impossible  early  in  labour,  and  the  diagnosis 
can  only  be  made  by  a  careful  bi-manual  examination  under 
anaesthesia.  When  the  cervix  dilates,  and  partial  moulding 
of  the  head  occurs,  the  presenting  part  comes  down  within 
reach.  If,  however,  the  risk  of  rupture  of  the  uterus  is  to 
be  avoided  early  diagnosis  is  necessary.  Accordingly,  in 
all  cases,  the  sign  upon  which  reliance  must  be  placed  is 


Fig.  240. — The  Skull  in  Hydrocephalus. 
(Ribemont-Dessaignes  and  Lepage.) 

the  recognition  by  bi-manual  examination  of  the  cephalic 
enlargement  ;  anaesthesia  is  required  for  this  during  labour, 
and  the  bladder  must,  of  course,  be  empty. 

The  maternal  risk  is  greatest  when  the  head  presents, 
for  if  the  condition  is  not  recognised,  over-distension  of  the 
lower  uterine  segment  leading  to  rupture  is  very  likely  to 
occur.  With  the  after-coming  head  there  is  less  risk,  as  the 
uterine  contractions  are  then  too  feeble  to  over-distend  the 
lower  uterine  segment. 

The  management  of  a  case  of  hydrocephalus  is  a  matter  of 
some  anxiety.  Spontaneous  delivery  is  not  to  be  anticipated, 
even  in  cases  of  moderate  size,  except  where  the  foetus  is 
macerated.     Some  method  of  reducing  the  size  of  the  head 


HYDROCEPHALUS  459 

is  practically  always  indicated.  The  chances  of  survival  of  a 
hydrocephalic  child  are  so  precarious  that  we  are  not  justified 
in  incurring  the  least  unnecessary  maternal  risk  in  delivery. 
Consequently  when  the  head  presents,  the  diagnosis  having 
been  confirmed  by  bi-manual  examination  under  anaesthesia, 
the  head  should  be  perforated  through  a  suture  or  a  fonta- 
nelle.  This  procedure  is  simple  and  easy.  If,  however, 
labour  has  been  in  progress  for  some  hours  and  the  signs  of 
distension  of  the  lower  uterine  segment  are  recognised 
(see  p.  463),  the  extraction  of  the  child  requires  great  care. 
Often  the  head  can  be  extracted  by  direct  traction  exerted 
by  a  finger  passed  into  the  skull  through  the  perforation 
aperture  and  aided  by  pressure  from  above  on  the  fundus 
(Birnbaun).  This  is  preferable  to  the  use  of  the  cranioclast 
or  cephalotribe  for  traction,  as  owing  to  the  softness  of  the 
cranial  structures  a  good  hold  cannot  be  obtained  and  the 
blades  are  therefore  liable  to  slip.  After  reducing  the  size 
of  the  head  version  may  be  performed,  but  this  should  not 
be  attempted  until  after  perforation  ;  the  after-coming 
head  can  then  be  extracted  with  comparative  ease.  When 
the  child  presents  by  the  breech  the  condition  of  the  head 
is  usually  unrecognised  until  the  trunk  has  been  born. 
Perforation  through  the  tubular  occipital  bone  or  through 
the  hard  palate  is  easy  as  a  rule.  If  owing  to  the  presence 
of  pelvic  contraction  the  head  is  too  high  to  be  easily  reached 
with  the  perforator,  it  is  safer  to  divide  the  vertebral  column 
in  the  upper  dorsal  region,  and  pass  a  catheter  up  the 
vertebral  canal  into  the  skull,  when  sufficient  fluid  may  be 
withdrawn  to  allow  of  the  delivery  of  the  head  by  gentle 
traction. 

Gigantism  and  in  some  cases  enlargement  of  the  trunk 
from  general  foetal  oedema  may  lead  to  great  difficulty  in 
delivering  the  trunk.  In  head  presentations  the  greatest 
obstacle  to  be  overcome  is  the  breadth  of  the  shoulders 
(bis-acromial  diameter).  This  prevents  trunk  rotation, 
and  thus  adds  to  the  difficulty.  The  bis-acromial  dia- 
meter can,  however,  be  effectually  reduced  by  division  of 
the  clavicles  (see  p.  749),  and  as  the  child  is  in  all  such  cases 
dead,  there  is  no  objection  to  this  procedure.  The  trunk 
can  then  be  delivered  by  steady  traction  applied  to  the 
axillae,  aided  by  pressure  from  above.      When  the  breech 


460 


ABNOmLlL   LABOUE 


presents  in  such  cases,  the  arms  invariably  become  extended 
and  the  difficulty  of  delivery  is  also  very  great.  Destructive 
operations  are  inevitablCj  and  evisceration  of  the  thorax  and 
abdomen  is  the  best  procedure  ;  it  will  then  be  possible  to 
reach  the  arms  to  deUver  them  in  the  usual  manner.  It  may. 
however,  also  be  necessary  to  perforate  the  after-coming 
head,    and   in  order   to   minimise   the   risks    of  injury  to 

the  matemal  passages,  this 
should  be  done  in  prefer- 
ence to  a  difficult  extraction 
by  some  other  method. 

F(Btal  Ahdomiival  En- 
largement.— The  commonest 
cause  of  congenital  enlarge- 
ment of  the  abdomen  is 
ascites  (Fig.  241)  ;  rarer 
causes  are  over-distension  of 
the  bladder  from  urethral 
stenosis,  cystic  tumours  of 
the  kidney  or  the  ovary,  and 
syphilitic  disease  of  the  liver. 
An  enlarged  abdomen  may 
cause  insuperable  obstruc- 
tion to  the  delivery  of  the 
trunk  ;  the  presentmg  part 
— head  or  breech — is  small, 
and  the  condition  will  there- 
fore as  a  rule  be  overlooked, 
untn  the  process  of  expulsion 
becomes  arrested.  Diagnosis 
can  be  estabhshed  by  pass- 
ing the  fingers  into  the 
vagina  under  anaesthesia,  and  carefully  estimating  the  size 
and  outline  of  the  retained  trunk.  The  treatment  is,  in 
the  case  of  fluid  swellings,  to  tap  the  abdomen,  and  under 
all  other  conditions  to  eviscerate. 

Double  Monsters.— These  are  twiu  foetuses  developed 
from  a  single  ovum,  and  organically  united  by  thek  trunks  ; 
some  vital  organ,  such  as  the  hver,  the  heart,  or  one  of  the 
great  arteries,  is  always  common  to  the  two.  The  differential 
diagnosis  from  locked  twins  may  be  very  difficult  dm-ing 


Fig.  241. — Foetal  Ascites.  • 
(Bibeinont-Dessaignes  and  Lepage.) 


RESULTS   OF   OBSTRUCTION  461 

labour.  Being  usually  small,  they  do  not  cause  such  serious 
obstruction  as  would  be  supposed,  and  spontaneous  delivery 
may  sometimes  occur.  Decapitation  or  evisceration  may  be 
necessary  if  the  foetuses  are  of  average  size. 

Clinical  Results  of  Obstruction. — All  of  the  conditions 
mentioned  above  do  not  invariably  give  rise  to  an  obstructed 
labour.  The  course  of  labour  is  greatly  influenced  by  two 
other  factors  in  addition  to  the  presence  of  some  cause  of 
obstruction  :  these  are  {a)  the  size  of  the  foetus,  (6)  the 
strength  of  the  uterine  contractions.  Thus,  many  of  the 
foetal  conditions  just  enumerated  will  not  cause  insuperable 
obstruction  if  the  foetus  is  of  small  size  :  e.g.,  transverse 
presentation  and  locked  twins.  And,  further,  a  degree  of 
obstruction  which  would  be  insuperable  to  a  feeble  uterus 
may  be  overcome  when  the  uterus  contracts  powerfully. 
The  influence  of  the  uterine  contractions  is  especially  impor- 
tant in  the  case  of  vertex  presentations  in  a  contracted  pelvis, 
for  the  moulding  of  the  head  necessary  for  its  passage  through 
the  pelvis  will  not  occur  unless  the  uterus  acts  powerfully. 
Accordingly  a  multipara  with  slight  pelvic  contraction  who 
has  been  delivered  either  spontaneously  or  with  the  aid  of 
forceps  in  her  early  labours,  may  suffer  from  insuperable 
obstruction  in  the  later  ones,  owing  to  the  enfeeblement  of 
the  uterus. 

The  results  of  obstruction  to  labour  are  extremely  serious, 
unless  the  condition  is  recognised  and  appropriately  treated 
early  in  labour.  If  exhaustion  of  the  uterus  (secondary 
inertia)  occurs,  danger  is  postponed,  at  any  rate  for  a  time. 
Sometimes  tonic  contraction  will  come  on,  and  may  lead  to 
the  death  of  the  undelivered  patient  from  exhaustion.  More 
frequently  obstruction  leads  to  over-distension  of  the  lower 
uterine  segment,  and  rupture  of  the  uterus  or  of  the  uterus 
and  vagina. 

Exhaustion  from  obstructed  labour  is  characterised  by 
local  signs  of  tonic  uterine  contraction,  rise  of  temperature, 
rapidity  of  pulse  and  respiration,  dry  tongue,  oedema  and 
arrest  of  secretion  of  the  walls  of  the  vagina  and  vulva,  and 
jfinaUy  delirium  or  convulsions  terminating  in  death.  The 
signs  of  over-distension  of  the  lower  uterine  segment  will  be 
described  in  connection  with  the  mechanism  of  uterine 
rupture. 


462  ABNOR]\IAL   LABOUR 

Diagnosis. — Most  of  the  conditions  liable  to  cause  serious 
obstruction  in  labour  are  capable  of  recognition  by  careful 
and  systematic  examination  during  the  latter  weeks  of 
pregnancy.  Exceptions  to  this  statement  are  brow  pre- 
sentations, locked  twins,  and  foetal  abdominal  enlargements  ; 
the  maternal  causes  are  all  discoverable  before  labour. 
When  an  ante-partum  diagnosis  has  been  made,  suitable 
measures  may  be  adopted  in  advance  for  the  safe  delivery  of 
the  patient,  and  the  importance  of  prophylaxis  in  these 
cases  cannot  be  over-estimated.  When  the  diagnosis  is  not 
made  until  labour  has  begun,  the  conditions  are  of  course 
less  favoui'able,  and  the  longer  labour  has  been  m  progress 
before  the  obstruction  is  discovered  the  graver  is  the 
prognosis. 

There  are  certain  conditions  m  labour  which  should  at 
once  arouse  the  suspicion  of  some  cause  of  obstruction ;  thus 
if  the  mother  shows  obvious  bony  deformity  or  is  stunted 
in  stature  ;  if  the  presentation  cannot  be  made  out  owing  to 
the  presenting  part  bemg  unusuallj^  high  ;  if  notwithstand- 
ing good  uterine  pains  the  presentmg  part  does  not  come 
down  after  the  membranes  have  ruptured  ;  if  the  vaginal 
walls  become  swollen  from  oedema,  or  the  presenting  parts 
obscured  b}^  a  large  caput  ;  if  a  swelling  is  found  m  the  j)elvis 
below  the  presenting  part.  In  each  of  these  conditions 
serious  obstruction  may  be  present.  Careful  exammation 
under  anaesthesia,  including  an  accurate  measurement  of 
the  diagonal  conjugate,  must  be  made  m  all  such  cases. 

Rupture  of  the  Uterus 

Rupture  of  the  uterus  is  the  most  serious  accident  which 
can  occur  in  labour.  It  may  take  place  under  varyuig  con- 
ditions, and  two  distinct  varieties  must  be  recognised — viz., 
traumatic  rupture  and  spontaneous  rupture.  Traumatic 
rwpture  is  met  with  in  very  rare  instances  in  pj'egnancy  from 
direct  violence,  such  as  a  faU,  or  a  blow  or  kick  upon  the 
abdomen  ;  more  commonly  it  occurs  during  labour,  and  is 
due  to  mtra-uterine  manipulations  such  as  version,  artificial 
dilatation  of  the  cervix,  destructive  operations  (foetal),  or 
forceps  extraction,  performed  either  unskilfully  or  under 
unfavourable    conditions.     Spontaneous   rupture   is    almost 


UTERINE   RUPTURE  463 

unknown  except  during  labour,  and  may  be  due  to  three 
different  conditions,  {a)  It  may  be  due  to  over-distension 
of  the  lower  uterine  segment  from  insuperable  obstruction. 
(6)  It  may  be  due  to  uterine  defects  such  as  malpositions 
{e.g.  pendulous  belly  and  anteversion  from  ventro-fixation), 
weakening  of  the  uterine  wall  by  cicatrices  of  previous 
Csesarean  section,  congenital  malformations  such  as  bicor- 
nute  uterus,  &c.  (c)  In  very  rare  instances  it  occurs  during 
normal  labour,  or  sometimes  even  during  pregnancy,  with 
an  apparently  healthy  uterus  ;  the  explanation  of  the 
accident  under  these  circumstances  is  obscure,  but  isolated 
cases  have  been  reported  in  which  cloudy  or  fatty  degenera- 
tion of  the  uterine  muscle  has  been  subsequently  demon- 
strated. 

Multiparity  must  be  recognised  as  a  powerful  predisposing 
cause  of  both  varieties,  for  in  94  per  cent,  of  cases  the  victims 
of  this  accident  are  multiparse.  This  is  explained  partly  by 
the  weakening  of  the  uterine  wall  which  results  from  frequent 
childbearing,  and  partly  from  the  increased  frequency  of  such 
causes  of  obstruction  as  mal-presentations.  The  frequency  of 
occurrence  of  rupture  of  the  uterus  is  estimated  at  about 
1  in  3,000  labours. 

Mechanism  of  Rupture. — (1)  Over-dis tension  of  the  lower 
uterine  segment. — This  is  the  essential  cause  of  spontaneous 
rupture  in  all  cases  due  to  obstruction.  It  has  been  already 
explained  that  in  normal  labour  the  uterine  wall  becomes 
differentiated  into  an  upper  active  part  which  retracts  as 
labour  proceeds,  and  a  lower  passive  part  which  becomes 
dilated  and  stretched  ;  separating  the  two  is  a  well-defined 
ridge,  called  the  retraction  ring,  or  the  ring  of  Bandl  (see 
p.  274).  Sometimes  in  normal  labour  this  ring  can  be 
palpated  by  abdominal  examination  in  the  form  of  a  shallow 
groove  above  the  level  of  the  pubes.  In  an  obstructed 
labour — e.g.  an  uncorrected  transverse  presentation — these 
changes  in  the  uterus  become  greatly  exaggerated  ;  retrac- 
tion proceeds  to  an  extreme  degree  in  the  active  portion, 
while  distension  becomes  correspondingly  extreme  in  the 
passive  portion,  for  the  reason  that  the  latter  is  now  made  to 
accommodate  the  greater  part  of  the  body  of  the  foetus 
(Figs.  201  and  242).  In  consequence,  the  ring  of  Bandl 
rises  up  to,  or  even  above,  the  level  of  the  umbilicus,  and 


464 


ABNORMAL  LABOUR 


usually  runs  obliquely  across  the  uterus.     The  wall  of  the 
distended  lower  segment  is  greatly  thinned,  especially  in 


-terus 


Retraction  ring 


Retraction 
ring 


Fig.  242.— Over-Distension  of  the  Lower  Uterine  Segment 
in  Transverse  Presentation.     (Bunim.) 

the  position  occupied  by  the  head,  and  tightly  stretched  over 
the  body  of  the  foetus  ;  it  is  in  imminent  danger  of  giving 
way  before  the  continuous  pressure  of  the  active  part  of  the 


UTERINE   RUPTURE  465 

uterus,  which  is  in  a  state  of  tonic  contraction.  Accordingly, 
rupture  produced  in  this  manner  always  begins  in  the  lower 
segment,  but  may  extend  upwards  into  the  body,  or  down- 
wards into  the  cervix  and  vagina. 

Over-distension  of  the  lower  segment  may  be  clinically 
recognised  in  the  following  manner  :  On  examination  of  the 
abdomen  the  uterus  will  be  found  to  be  hard  and  tender  ;  the 
outlines  of  the  foetus  will  be  obscure  and  its  mobility  limited  ; 
the  foetal  heart  probably  inaudible  ;  the  ring  of  Bandl  will  be 
recognisable  as  an  oblique  groove  at  about  the  level  of  the 
umbilicus  ;  and  one  or  both  round  ligaments,  tightly 
stretched  over  the  distended  lower  segment,  may  also  be 
felt  crossing  obliquely  the  front  of  the  uterus  in  a  direction 
(downwards  and  outwards  towards  the  middle  of  Poupart's 
Mgament.  It  will  be  remembered  that  the  round  ligaments 
ibecome  considerably  hypertrophied  during  pregnancy.  On 
waginal  examination  the  conditions  found  will  closely  resemble 
those  characteristic  of  tonic  contraction.  From  the  latter 
condition  over-distension  of  the  lower  segment  can  best  be 
distinguished  by  the  position  of  the  retraction  ring. 

(2)  Intra-uterine  Manipulations.— Such  procedures  as- 
those  named  above  may,  from  want  of  skill  or  care,  cause 
rupture  of  the  uterus  when  there  is  no  abnormality  in  labour  ; 
they  are,  however,  much  more  likely  to  cause  this  accident 
when  carried  out  under  unsuitable  conditions,  such  as 
complete  escape  of  liquor  amnii,  tonic  contraction,  or  over- 
distension of  the  lower  uterine  segment.  Under  these  cir- 
(cumstances  the  introduction  into  the  uterus  of  the  hand, 
(or  even  of  a  small  instrument  such  as  a  decapitation  hook, 
is  very  likely  to  cause  the  uterine  wall  suddenly  to  give  way. 
(-Cases  of  this  kind  must  be  regarded  as  instances  of  traumatic 
rupture,  for  although  the  condition  of  the  uterus  is  a  power- 
ful predisposing  cause,  rupture  is  not  spontaneous.  Also, 
methods  of  rapidly  dilating  the  cervix  in  labour  are  always 
attended  by  risks  of  rupture  of  the  cervix  and  lower  segment, 
for  proper  regulation  of  the  amount  of  force  employed  is 
very  difficult.  Again,  the  extraction  of  the  head  by  forceps 
through  an  imperfectly  dilated  cervix  may  cause  a  deep 
cervical  tear  which,  if  much  force  is  employed,  may  spread 
upwards  into  the  lower  uterine  segment,  and  according  to  its 
situation  may  lay  open  either  the  peritoneal  cavity,  the  broad 
E.M.  30 


466  ABNORMAL   LABOUR 

ligament,  or  the  bladder.    These  injuries  necessarily  involve 
deep  laceration  of  the  vaginal  vault  as  well. 

Li  most  cases  due  to  intra-uterine  manipulations  the 
rupture  starts  in  the  cervix  or  lower  uterine  segment  ;  thence 
it  runs  up  into  the  body  and  usually  follows  the  lateral 
uterine  wall,  opening  up  the  broad  ligament.  The  majority 
of  such  cases  are  therefore  cases  of  incomplete  rupture. 
Extensive  lacerations  may,  however,  open  the  peritoneal 
cavity  at  once,  and  numerous  cases  have  been  recorded  in 
which  a  tear  has  been  produced  in  this  way,  extending  from 
the  fundus  above,  through  the  uterine  body,  lower  segment, 
and  cervix,  into  the  lateral  vaginal  wall.  Li  all  such  cases, 
where  considerable  force  has  been  employed  to  effect  delivery, 
extensive  bruising  and  laceration  are  also  usually  found  at 
the  vulva,  involvmg  the  perineal  body  and  the  labia. 

(3)  Abnormalities  of  the  Uterus. — Certain  abnormal  con- 
ditions of  the  uterus  may  be  the  cause  of  spontaneous 
rupture  or  may  predispose  to  traumatic  rupture.  They  may 
be  enumerated  as  follows  : 

Cicatrices  of  previous  Csesarean  section. 
Fatty  or  cloudy  degeneration  of  the  uterme  muscle. 
Bicornute  uterus  (rarely). 
Uterine  tumours  (carcinoma  of  cervix). 
Misdirection  of  the  uterine  axis. 

Rupture  through  a  Csesarean  section  scar  is  usually 
longitudinal  and  situated  in  the  anterior  wall  near  the  mid- 
line (Fig.  243) ;  it  may,  however,  be  transverse  and  situated 
upon  the  fundus  (see  p.  727).  Conditions  1  and  2  may  explain 
the  very  rare  cases  already  alluded  to  in  which  spontaneous 
rupture  of  the  uterus  occurs  in  pregnancy  or  in  unobstructed 
labour.  Disease  ef  the  uterine  muscle  can  only  be  recognised 
by  microscopic  examination  of  the  organ  after  its  removal 
from  the  body.  When  pregnancy  occurs  in  one  horn  of  a 
bicornute  uterus,  the  non-gravid  horn  may  be  found  during 
labour  to  occupy  a  position  in  which  it  obstructs  the  passage 
of  the  foetus  through  the  pelvis,  and  may  then  lead  to  rupture 
from  distension  of  the  lower  uterine  segment.  It  is  extremely 
rare  for  uterine  tumours  to  cause  rupture. 

Misdirection  of  the  Uterine  Axis  is  the  chief  cause  of 
rupture  in  cases  of  "  pendulous  belly  "  (Fig.  59)  ;  in  this 
condition  the  axis  of  the  uterus  is  directed  against  the  pos- 


UTERINE   RUPTURE  467 

terior  wall  of  the  lower  uterine  segment,  and  if  the  displace- 
ment is  not  corrected  during  labour  the  presenting  part  may 
be  driven  through  the  uterine  wall  at  this  spot.  Extreme 
lateral  obliquity  may  similarly  predispose  to  rupture.     Cases 


Fig.  243. — Eupture  of  the  Uterus  through  a  Ceesarean  Section  Scar. 

(Cameron.) 

of  spontaneous  rupture  may  be  also  due  to  previous  opera- 
tions in  which  unsuitable  methods  have  been  employed  for 
fixing  the  body  of  the  uterus  to  the  anterior  abdominal  wall, 
or  the  anterior  vaginal  wall.  During  pregnancy  the  develop- 
ment of  the  attached  part  of  the  uterus  may  then  be  greatly 
retarded,  the  uterus  growing,  in  point  of  fact,  almost  entirely 

30—2 


468 


ABNORMAL  LABOUR 


at  the  expense  of  its  posterior  wall,  which  is  consequently 
very  much  thinner  and  weaker  than  normal  at  term.  There 
is  also  marked  backward  and  upward  displacement  of  the 
cervix,  in  consequence  of  which  the  normal  mechanism  of 
parturition  is  greatly  modified. 

Morbid  Anatomy. — Rupture  of  the  uterus  is  said  to  be 
complete  when  all  the  coats  including  the  peritoneum  are  torn, 
and  incoviplete  when  this  is  not  the  case.  Rupture  of  the 
lateral  wall  of  the  uterus,  which  in  pregnancy  is  uncovered  by 
peritoneum  (see  p.  67),  may  involve  the  whole  thickness  of 


EiG.  244. — Incomplete  Uterine  Eupture  involving  the  Peritoneal 
Coat  only.     (Von  Winckel.) 

the  muscular  wall  and  still  be  incomplete,  as  it  merely  opens 
up  the  broad  ligament,  but  does  not  tear  the  peritoneum. 
Further,  an  incomplete  rupture  openmg  up  the  broad  liga- 
ment may  subsequently  become  complete  by  the  peritoneal 
layer  yielding,  either  from  the  pressure  of  accumulated  blood, 
from  a  portion  of  the  body  of  the  foetus  being  driven  through 
it  by  uterine  retraction,  or  from  manipulation  of  the  torn 
parts.  Incomplete  rupture  sometimes  involves  chiefly  the 
peritoneal  coat,  occurring  in  the  form  of  superficial  lacera- 
tions which  gape  and  may  bleed  freely  (Fig.  244)  ;  the  causa- 
tion of  this  rare  accident  is  obscure. 

Cases  of  spontaneous  rupture  are  more  often  complete 


UTERINE  RUPTURE 


469 


than  incomplete  ;  cases  of  traumatic  rupture  are  more  often 
incomplete  than  complete.  In  the  great  majority  of  cases 
rupture  commences  in  the  lower  uterine  segment,  the  reason 


Retraction 
ring 


Distended    lower 

uterine    segment 

with  longitudinal 

teax 


Os  externum 


Pig.  245.  Eupture  of  the  Uterus  limited  to  the  Lower  Segment,  whicli 
is  greatly  distended ;  the  Distension  is  greater  on  one  side  than  the 
other.     (Bumm.) 

being  that  this  part  of  the  wall  is  thinnest  and  is  also  most 
liable  to  over-distension.  The  rupture  may  be  confined  to 
the  lower  segment  (Fig.  245),  or  may  extend  upwards  into 
the  uterine  body,  even  to  the  fundus,  or  downwards  into  the 
vaginal  fornices  ;    the  bladder  is  occasionally  involved  in 


470 


ABNORMAL   LABOUR 


tears  of  the  anterior  wall.  In  cases  due  to  abnormalities  of 
the  uterus,  the  tear  often  commences  above  the  lower  seg- 
ment— e.g.,  the  scar  of  a  Csesarean  section  may  give  way. 
The  direction  of  the  tear  is  in  the  majority  of  cases  oblique  ; 
occasionally  it  may  be  transverse,  and  sometimes  a  trans- 


Right 

ovary 


Fig.  246. — Piiipture  of  tlie  Lateral  Wall  of  tlie  Uterus  involving 
Lower  Segment  and  Cervix.     (Edgar.) 


verse  tear  encircles  nearly  the  whole  lower  segment,  practi- 
cally cutting  the  uterus  in  two  ;  occasionally  it  is  vertical, 
such  tears  occurring  most  frequently  on  the  lateral  wall  of 
the  uterus  (Fig.  245).  In  rare  instances  transverse  rupture 
starts  in,  and  is  limited  to,  the  fundus  (Fig.  247).  Fundal 
rupture  in  most  recorded  instances  has  been  attributed  to 
abnormal  thinning  of  the  placental  site  ;    it  may,  however, 


UTERINE   RUPTURE 


471 


occur  through  the  cicatrix  of  a  previous  Csesarean  section. 
Sometimes  rupture  causes  laceration  of  a  large  branch  of  the 
uterine  or  vaginal  artery,  or  of  large  uterine  veins  (Fig.  246)  ; 
serious  haemorrhage  then  occurs  ;  this  is,  however,  by  no 
means  the  rule,  and  if  the  large  vessels  escape,  the  amount 
of  haemorrhage  may  be  trifling.  Complete  rupture  of  con- 
siderable extent  involving  the  peritoneal  coat  is  usually 
followed  by  the  escape  of  the  uterine  contents  (foetus  or 


Fig.  247. — Complete  Transverse  Eupture  of  the  Fundus  Uteri. 

(Von  Winckel.) 


placenta,  or  both)  into  the  peritoneal  cavity  ;  the  empty 
uterus  then  retracts  firmly  and  severe  haemorrhage  will  be 
impossible,  unless  large  vessels  have  been  torn.  When  the 
rupture  is  small  or  incomplete  the  foetus  remains  in  the 
uterine  cavity.  Sometimes  a  part  only  of  the  foetus — the 
head  or  a  limb — escapes  through  the  rupture,  the  remainder 
being  retained  in  the  uterus  ;  firm  retraction  of  the  edges  of 
the  rent  upon  the  extruded  part  may  then  occur,  preventing 
the  withdrawal  of  the  foetus  per  vias  naturales. 


472  ABNORMAL  LABOUR 

Diagnosis. — In  order  to  establish  the  diagnosis  of  rupture 
of  the  uterus,  it  is  usually  necessary  to  recognise  the  lacera- 
tion by  touch.  The  symptoms  which  attend  this  grave 
accident  are  not  characteristic,  although  they  may  arouse 
the  suspicion  that  rupture  has  occurred. 

Premonitory  syinptoms  of  rupture  are  sometimes  de- 
scribed ;  these  are,  in  pomt  of  fact,  a  history  of  a  long  and  diffi- 
cult labour  leading  up  to  the  symptoms  already  mentioned 
as  those  of  tonic  contraction  and  over-distension  of  the  lower 
uterine  segment  (p.  449).  But  it  must  be  borne  in  mind  that 
although  in  the  majority  of  cases  a  long,  difficult,  and  painful 
labour  precedes  rupture,  this  is  not  always  the  case,  for 
spontaneous  rupture  may  occur  early  in  normal  labour. 

The  attendant  symptoms  are  probably  influenced  mamly 
by  the  rapidity  with  which  the  laceration  is  produced,  and 
the  amount  of  hsemorrhage  which  accompanies  it.  Sudden 
rupture  is  attended  by  severe  shock  and  acute  abdominal 
pain,  sometimes  also  by  the  sensation  that  something  has 
burst  and  by  the  sudden  cessation  of  the  pains,  which  have 
been,  in  most  cases,  unusually  severe.  There  may  be  some 
external  bleeding,  but  this  is  seldom,  if  ever,  profuse  ;  the 
greater  part  of  the  effused  blood  is  retained  when,  if  a  large 
vessel  has  been  torn,  signs  of  more  or  less  severe  internal 
haemorrhage  gradually  manifest  themselves.  Occasionally 
internal  haemorrhage  may  be  so  profuse  as  to  cause  death  in 
an  hour  or  two.  Incomplete  rupture  produces  much  less 
severe  symptoms,  and  less  profuse  haemorrhage  than  com- 
plete rupture.  It  may  accordingly  be  said  that  the  chief 
symptoms  pointing  to  the  occurrence  of  rupture  are  the 
sudden  or  rapid  development  of  symptoms  of  shock — e.g., 
paUor,  cold  clammy  skm  and  rapid  pulse,  in  a  case  in  which 
labour  has  been  long,  or  artificial  delivery  has  been  accom- 
plished with  difficulty.  When  also  there  is  external  bleeding, 
and  though  delivery  has  not  taken  place  the  pains  suddenly 
cease,  the  presumption  is  greatly  strengthened. 

Abdommal  examination  yields  no  certain  information 
unless  the  foetus  has  escaped  from  the  uterus,  when  the 
physical  signs  are  striking.  The  foetal  parts  can  be  palpated 
with  great  ease  through  the  abdominal  wall  ;  there  is  also 
extreme  mobility  both  of  the  limbs  and  of  the  whole  body. 
In  the  lower  abdomen  the  hard  retracted  uterus  will  be  found 


UTERINE    RUPTURE  473 

of  the  size  natural  to  the  termination  of  the  third  stage  of 
labour,  and  quite  separate  from  the  foetus.  If  the  foetus 
remains  in  the  uterus  after  rupture  has  occurred,  it  is  seldom 
possible  to  make  the  diagnosis  until  after  delivery. 

Whenever  it  is  suspected  before  delivery  that  rupture 
has  occurred,  a  careful  examination  under  anaesthesia  should 
be  made,  the  whole  hand  being  passed  into  the  vagina  for 
this  purpose,  as  it  is  obviously  necessary  to  reach  the  lower 
uterine  segment.  If  the  laceration  has  involved  the  vaginal 
vault,  the  lower  end  of  the  tear  will  be  easily  found  ;  the  full 
extent  of  the  injury  is  often  difficult  to  estimate  until  the 
uterus  is  empty. 

In  many  cases,  however,  the  suspicion  of  rupture  does 
not  arise  until  after  the  delivery  of  the  patient,  either  with 
or  without  artificial  aid.  The  bad  general  condition  of  the 
patient  then  attracts  attention,  and  definite  symptoms  of 
severe  shock  may  supervene.  If  the  placenta  has  escaped 
through  the  rent  into  the  peritoneal  cavity,  attempts  to 
deliver  it  in  the  ordinary  way  will  be  unsuccessful  ;  in  some 
cases  considerable  external  bleeding  occurs  although  the 
placenta  has  been  delivered  and  the  uterus  is  firmly  retracted, 
or  the  patient  may  show  immediate  signs  of  collapse  ;  but  in 
some  cases  suspicion  of  rupture  has  not  been  aroused  for 
several  hours  after  the  termination  of  labour,  owing  to  the 
gradual  development  of  the  symptoms.  Under  all  such  cir- 
cumstances as  these,  careful  search  should  be  made  for  rup- 
ture. If  the  placenta  has  escaped  through  the  rent  into  the 
peritoneal  cavity,  the  cord  will  guide  the  fingers  up  to  and 
through  the  rent.  Occasionally  a  coil  of  small  intestine  may 
protrude  through  the  rupture  into  the  vagina.  It  is  a  point 
of  practical  importance  to  decide  whether  the  rupture  is 
complete  or  incomplete,  for  treatment  depends  upon  this 
point  to  some  extent.  If  a  coil  of  intestine  has  prolapsed, 
or  if  the  finger  passed  through  the  tear  definitely  detects 
bowel  or  any  other  organ,  such  as  the  omentum  or  the  ovary, 
it  is  certain  that  the  rupture  is  complete.  In  incomplete 
rupture  opening  up  the  broad  ligament  extensively,  a  thin 
layer  of  peritoneum  and  cellular  tissue  intervenes  between  the 
viscera  and  the  finger,  and  prolapse  of  gut  cannot  occur. 

Risks. — Rupture  of  the  uterus  during  labour  is  one  of  the 
most  serious  accidents  which  can  befall  a  parturient  woman. 


474  ABNORMAL   LABOUR 

The  mortality  has  been  estimated  by  various  authorities  at 
from  70  to  80  per  cent.  ;  for  cases  treated  under  favourable 
conditions  such  as  are  offered  by  Lying-in  Hospitals  it  is 
probably,  under  modern  methods,  not  more  than  50  to  60 
per  cent.  (Munro  Kerr).  But  even  this  modified  rate  is 
extremely  high.  The  immediate  risks  are  those  associated 
with  shock  and  haemorrhage  ;  if  the  patient  survives  these  she 
has  still  to  encounter  the  more  remote  risks  of  septic  infec- 
tion. Shock  and  haemorrhage  occur  together,  and  the  in- 
fluence of  the  two  in  determining  a  fatal  result  cannot  be 
separately  estimated  ;  deaths  occurring  within  twenty-four 
hours  of  delivery  are  practically  all  due  to  these  causes. 
Probably  50  per  cent,  of  the  mortahty  is  the  result  of  com- 
bined shock  and  haemorrhage,  the  remaining  50  per  cent, 
being  due  to  sepsis.  The  frequent  occurrence  of  septic 
infection  is  to  be  explamed  by  two  considerations.  Firstly, 
rupture  of  the  uterus  is  as  a  rule  the  direct  outcome  of 
bad  obstetrics,  as  in  the  case  of  failure  to  recognise  a 
transverse  presentation,  or  of  untimely  or  unskilful  operative 
interference.  Consequently  it  is  among  the  poorest  classes 
that  cases  of  rupture  usually  occur,  and  in  these  patients 
insanitary  surroundings,  want  of  personal  cleanliness,  and 
absence  of  trained  nursing  attendance  all  favour  the  occur- 
rence of  sepsis.  When  a  woman  suffering  from  this  injury  is 
brought  to  hospital  for  treatment  she  has  in  many  cases 
been  already  infected.  Secondly,  even  if  skilled  attendance  in 
labour  has  been  available,  the  existence  of  an  extensive 
internal  laceration  throwing  the  vaginal  canal  into  direct 
communication  with  the  peritoneal  cavity  or  the  pelvic 
cellular  tissue,  offers  unusual  facilities  for  the  spread  of  any 
infective  agent  which  may  gain  admission. 

Treatment. — This  mast  be  considered  from  two  points  of 
view  :  (1)  how  to  deliver  the  patient  ;  (2)  how  to  deal  with 
the  rupture. 

(1)  If  it  is  believed,  after  careful  examination,  that  the 
foetus  is  still  in  the  uterine  cavity,  an  attempt  should  be 
made  to  deliver  it  through  the  natural  passages  ;  causes  of 
obstruction  must  be  carefully  looked  for  and  estimated,  and 
suitable  methods  of  extraction  then  adopted.  If  the  pre- 
sentation is  an  impacted  shoulder  no  attempt  at  version  should 
be  made  ;  but  the  child  may  be  delivered  by  decapitation, 


UTERINE   RUPTURE  475 

or  by  some  method  of  embryotomy  if  the  neck  is  difficult 
to  reach  (see  p.  740).  Intra -uterine  manipulations  under 
these  circumstances  are  certain  greatly  to  increase  the  tear 
if  it  has  already  occurred.  If  a  part  of  the  foetus  has  escaped 
through  the  rent,  attempts  at  deliver}^  through  the  natural 
passages  must  be  very  gently  made.  As  the  foetus  is  in  all 
cases  dead,  destructive  operations  may  be  practised  without 
hesitation.  If  the  foetus  has  been  expelled  completely  into 
the  peritoneal  cavity,  laparotomy  is  the  only  possible  method 
of  delivery  which  can  be  adopted.  If  the  child  is  born 
but  the  placenta  has  escaped  from  the  uterus,  the  placenta 
may  be  drawn  down  by  traction  on  the  cord  and  delivered 
with  care  through  the  rent. 

(2)  The  treatment  of  the  rupture  is  in  all  cases  a  matter  of 
difficulty,  and  great  differences  of  opinion  have  been  expressed 
as  to  the  best  method  of  dealing  with  it.  Upon  one  point 
there  is  agreement,  viz.  that  the  immediate  indications  are 
to  ascertain  the  full  extent  of  the  injury,  and  to  adopt 
energetic  measures  to  diminish  shock.  The  entire  hand 
should  be  passed  into  the  vagina  immediately  after  delivery, 
so  that  the  position  and  size  of  the  laceration  may  be  clearly 
determined.  Special  attention  should  be  paid  to  two 
points — whether  the  tear  has  opened  the  peritoneal  cavity 
or  has  injured  the  bladder.  The  amount  of  external  bleeding 
is  usually  slight,  but  the  uterine  cavity  should  be  freely 
irrigated  with  normal  saline  solution,  and  the  vaginal  walls 
thoroughly  irrigated  and  swabbed  with  lysol  solution,  a 
teaspoonful  to  a  pint.  When  the  general  condition  of  the 
patient  is  grave,  and  there  is  severe  shock,  nothing  further 
should  be  done  until  certain  restorative  measures  have  been 
adopted. 

The  essential  feature  of  shock  is  profound  depression  of 
the  circulation,  indicated  by  a  small,  soft  and  rapid  pulse, 
coldness  and  pallor  of  the  skin  with  slight  cyanosis  of  the 
lips.  The  temperature  is  sub-normal,  the  respiration 
shallow  but  not  greatly  quickened,  the  mental  condition 
lethargic  ;  or  there  may  be  loss  of  consciousness.  The 
reaction  is  indicated  first  by  improvement  in  the  pulse,  and 
then  by  a  return  of  warmth  to  the  body  surface.  When 
there  is  severe  shock  the  patient  should  be  kept  recumbent 
with  the  foot  of  the  bed  raised  ;   if  it  is  desired  to  move  her 


476  ABNORI^IAL   LABOUR 

into  hospital  this  should  be  postponed  until  some  degree  of 
reaction  has  been  obtained.  The  two  chief  requirements  in 
the  treatment  of  shock  are  the  a23i3hcation  of  warmth  to  the 
body,  and  the  rapid  introduction  of  fluid  into  the  circulation. 
If  hot  baths  and  bottles  are  used,  great  care  must  be  taken 
to  keep  them  from  contact  with  the  skin,  as  severe  burns  are 
produced  by  a  comparatively  low  temperatm^e  dm-ing  shock. 
In  hospital  practice  the  electric  light  bath  is  a  convenient 
method  of  applying  heat  and  may  be  continued  until  sweatmg 
begins,  when  its  temperature  should  be  gradually  reduced. 
Fluids  cannot  be  administered  in  large  quantity  by  the 
mouth,  but  may  be  given  per  rectum,  subcutaneously  or  by 
intra-venous  transfusion.  The  rectal  method  is  inadequate 
except  for  shght  cases  ;  the  subcutaneous  method  will  suffice 
for  aU  but  the  gravest  cases,  when  intra-venous  transfusion 
must  be  resorted  to.  By  the  latter  method  success  may  be 
attained  even  when  the  patient  appears  to  be  moribund. 
Alcohol  and  strychnine  are  of  little  use  and  by  some  authori- 
ties are  held  to  be  harmful.  The  most  useful  drug  in  shock 
is  pituitary  extract,  which  may  be  given  along  with  the 
subcutaneous  injection  of  saline  in  doses  of  1  c.c.  of  a  20  per 
cent,  solution  ;   its  effect  is  to  raise  blood  pressure. 

The  treatment  of  the  injury  itself  may  be  either  expectant 
or  operative.  Expectant  treatment  consists  in  establishing 
free  vaginal  drainage  from  the  lacerated  parts,  combined  with 
plugging  of  rents  or  of  cavities  with  gauze,  if  requned  for  the 
control  of  oozing  or  of  more  active  haemorrhage.  Probably 
a  better  method  is  to  drain  by  means  of  large  rubber  tubes 
which  must  be  stitched  in  position,  and  made  to  pass  deeply 
above  the  level  of  the  lacerations.  Thus  the  tubes  may  pass 
into  the  peritoneal  cavity,  or  into  the  widely  opened  pelvic 
ceUular  tissue  in  cases  of  incomplete  rupture  opening  up  the 
broad  ligament.  In  aU  cases  where  the  surroundings  of  the 
patient  are  unfavourable  for  the  performance  of  a  serious 
surgical  operation  the  expectant  method  should  be  adopted. 
In  cases  of  incomplete  rupture  it  may  be  possible  by  making 
traction  on  the  uterus  to  pull  it  down  to  the  vulva  sufficiently 
to  aUow  of  the  laceration  in  the  uterine  waU  being  directly 
closed  with  stitches.  The  broad  hgament  cavity  then 
remains  in  communication  with  the  vagina  only ;  it 
should  not  be  closed,  but  plugged  with  a  strip  of   gauze 


UTEREN'E   RUPTURE  477 

or  drained  with  a  rubber  tube.  Operative  treatment  of 
complete  rupture  consLsts  in  opening  the  abdomen,  and 
after  carefully  investigating  the  position  and  extent  of  the 
injuries,,  either  removing  the  ruptured  uterus  altogether  by 
hysterectomy,  or  sewing  up  the  lacerations.  If  the  patient 
survives  the  operation  the  risk  of  sepsis  has  been  practically 
eliminated.  When  rupture  has  been  followed  by  escape  of 
the  child  into  the  peritoneal  cavity  an  abdominal  operation 
must  ui  all  cases  be  performed  in.  order  to  deliver  the  child, 
and  this  allows  of  the  rupture  beiag  at  the  same  time  dealt 
with. 

The  advantage  of  the  operative  treatment  is  that  the  full 
extent  of  the  injury  can  be  discovered,  haemorrhage  com- 
pletely arrested,  bruised  or  possibly  infected  tissues  or 
organs  removed,  the  peritoneal  cavity  cleansed,  and  free 
drainage  provided  both  by  the  supra -pubic  and  vaginal 
routes.  When  the  laceration  is  not  very  extensive,  and  is 
situated  in  an  accessible  position,  it  may  be  stitched  up  and 
the  uterus  saved.  But  experience  shows  that  a  high 
mortahty  from  sepsis  attends  this  procedure,  for  if  the  uterus 
is  infected  the  edges  of  the  tear  will  not  unite  and  septic 
peritonitis  then  ensues.  The  great  disadvantage  of  both 
forms  of  abdominal  operation  is  that  the  patient's  general 
condition  is  often  so  bad  that  the  performance  of  an  extensive 
operation  such  as  these  appears  to  be  almost  a  forlorn  hope. 
On  the  other  hand  the  expectant  method,  if  at  first  successful, 
is  attended  by  grave  risks  of  sepsis  in  convalescence,  for  the 
uterus  itseK  may  have  been  infected  during  labour,  and, 
further,  by  this  method  the  peritoneal  cavity  cannot  be 
thoroughly  cleansed.  And  again,  concealed  haemorrhage 
may  continue  from  some  deeply-placed  vessel. 

The  most  efficient  method  is  undoubtedly  to  operate 
and  remove  the  uterus  bv  hvsterectomv  :  thus  bleeding 
is  finally  controlled  and  the  risks  of  sepsis  avoided  as  far 
as  may  be.  But  by  many  obstetricians  the  severe  shock 
attending  rupture  of  the  uterus  is  held  of  itself  to  centra- 
indicate  such  a  severe  operation  as  this.  Recent  statistics, 
however,  appear  to  show  that  a  larger  percentage  of  recoveries 
attends  hysterectomy  than  any  other  method,  whether  opera- 
tive or  expectant,  of  dealing  with  bad  cases  of  rupture  of  the 
uterus.     It  is  probable  that  in  time  this  method  will  be 


478  ABNOR]\IAL   LABOUR 

generally  accepted  for  such  cases,  the  expectant  method  bemg 
reserved  for  those  in  which  the  injury  is  comparatively  slight. 

Lacerations  of  the  cervix  and  vagina  frequently  occur  in 
labour  and  are  of  mmor  importance.  A  certain  amount  of 
laceration  of  the  cervix  is  usual  m  a  primipara  and  requires 
no  treatment  ;  it  is  invariably  longitudinal  in  du'ection 
and  usually  lateral  in  position,  being  much  more  frequent 
upon  the  left  than  the  right  side.  This  is  explained  by  the 
predominant  frequency  of  the  first  vertex  position,  in  ^^hich 
the  broad  end  of  the  head  distends  the  left  side  of  the 
cervix.  Sometimes  these  lacerations  are  more  extensive 
and  run  up  to  the  vaginal  roof,  or  open  the  base  of  the  broad 
ligament  ;  they  should  then  be  treated  by  douchmg  the 
ragged  cavity  formed  bj'  the  tear,  and  draining  it  with  a 
large  rubber  tube.  Occasionally  transverse  rupture  of  the 
anterior  lip  occurs  from  non-dilatation  of  the  external  os, 
and  dehvery  takes  place  through  the  rent  which  is  situated 
in  front  of  the  undilated  os  (Fig.  237).  In  extensive  rupture 
of  the  lower  uterme  segment  the  laceration  frequently  extends 
downwards  so  as  to  mvolve  the  cervix  and  upper  part  of 
the  vaginal  wall. 

In  severe  laceration  of  the  pelvic  floor  the  lower  thh'd  of 
the  posterior  vagmal  wall  of  necessity  participates.  Vaginal 
lacerations  are  thus  most  frequent  in  the  upper  and  lower 
thirds.  They  may  also  occur  in  the  middle  third  in 
obstructed  labour  or  difficult  instrumental  delivery  ;  if  upon 
the  anterior  waU,  the  base  of  the  bladder  may  then  be 
lacerated,  giving  rise  to  a  vesico-vaginal  fistula.  Sometimes, 
from  prolonged  compression  between  the  fcetal  head  and  the 
pelvic  bones,  an  area  of  the  anterior  vaginal  wall  is  damaged 
beyond  recovery,  and  sloughing  occurs.  The  slough  then 
separates  during  the  first  week  of  the  puerperium,  and  may 
open  the  base  of  the  bladder,  resulting  in  a  vesico-vaginal 
fistula.  When  an  extensive  area  in  any  position  has 
sloughed,  the  process  of  cicatrisation  is  attended  by  well- 
marked  constriction,  and  may  result  in  vagmal  atresia  of 
extreme  degree.  Lacerations  of  the  cervix  and  vagmal 
roof  do  not  requh-e  suture  unless  there  is  considerable 
haemorrhage  ;  those  of  the  lower  third  of  the  vagina  should 
always  be  repaired  at  the  same  time  as  the  injury  to  the 
perineum. 


PELVIC  HEMATOMA  479 

Rupture  of  Veins  {Vaginal  and  vulval  hcematoma). — 
Large  effusions  of  blood  from  ruptured  veins  may  form 
beneath  the  vaginal  walls  during  labour.  The  cause  of 
rupture  of  the  vaginal  veins  is  not  well  known,  but  the 
accident  occurs  chiefly  in  prolonged  labour  or  operative 
delivery.  It  may  be  also  met  with  in  pregnancy  as  the 
result  of  direct  injury.  The  formation  of  the  hsematoma 
begins  beneath  one  of  the  lateral  vaginal  walls,  and  usually 
extends  downwards  into  the  labium  ma  jus,  forming  a 
characteristic  vulval  swelling  which  may  attain  considerable 
size.  Sometimes  the  tumour  does  not  extend  to  the  vulva, 
and  then  it  ca,n  be  recognised  only  by  vaginal  examination. 
The  vulval  swelling  presents  distinctive  characters  ;  it  is 
soft  and  fluctuating,  of  a  deep  violet  colour  where  covered 
with  mucous  membrane,  and  is  associated  with  subcutaneous 
ecchymosis,  extending  over  the  perineum,  around  the  anus, 
and  upon  the  inner  aspect  of  the  thighs. 

A  vaginal  hsematoma  may  form  during  the  second  stage 
of  labour,  and  cause  obstruction  to  delivery  ;  usually,  how- 
ever, it  appears  during  or  soon  after  the  third  stage.  It  is 
associated  with  severe  pain,  and  the  loss  of  blood  from  the 
general  circulation  may  be  sufficient  to  produce  urgent 
symptoms  of  internal  haemorrhage.  Occasionally  spon- 
taneous rupture  of  the  hsematoma  occurs,  leading  to  the 
escape  of  a  large  quantity  of  fluid  and  clotted  blood. 

The  treatment  is  expectant,  with  strict  antiseptic  manage- 
ment of  the  puerperium.  If  the  thrombus  should  become 
infected,  it  must  be  laid  freely  open,  the  cavity  cleared  out, 
douched,  and  packed  with  iodoform  gauze. 

Pelvic  Hoematoma. — The  occurrence  of  haemorrhage 
between  the  layers  of  the  broad  ligament  in  incomplete 
rupture  of  the  uterus  has  been  already  referred  to  ;  this 
condition  is  called  a  pelvic  hsematoma.  Rare  cases  have 
been  reported  in  which  the  same  condition  has  occurred 
without  injury  to  the  uterus,  the  source  of  the  bleeding  bemg 
ruptured  veins  in  the  connective  tissue  of  the  base  of  the 
broad  ligament.  Such  haemorrhages  may  be  very  extensive, 
dissecting  up  the  whole  of  the  pelvic  peritoneum,  passing  on 
to  the  abdominal  parietes  and  into  the  iliac  fossae,  and  giving 
rise  to  the  symptoms  of  severe  internal  haemorrhage.  Small 
effusions  which  give  rise  to  no  urgent  symptoms  require  no 


480  ABNORMAL   LABOUR 

operative  treatment  ;  but  if  the  patient's  condition  is  urgent, 
one  or  other  lateral  vaginal  fornix  should  be  opened,  the 
blood  evacuated,  and  the  cavity  douched  and  plugged  with 
iodoform  gauze. 

Rupture  of  the  Perineum. — This  minor  accident  is  of 
frequent  occurrence,  but  usually  of  small  importance.  It  is 
only  referred  to  here  in  order  to  emphasise  again  the  import- 
ance of  examining  the  perineum  in  every  case  after  delivery, 
and  of  immediately  repairing  all  lacerations  which  involve 
more  than  the  skin  of  the  fourchette.  Lacerations  involving 
the  sphincter  ani  are  of  great  importance,  because,  unless 
successfully  repaired,  troublesome  rectal  incontinence  will 
ensue.  The  chief  varieties  of  perineal  rupture,  along  with 
the  suitable  methods  of  repair,  are  described  upon  p.  755. 

Inversion  of  the  Uterus 

This  condition  is  a  turning  inside  out  of  the  uterus.  It 
is  one  of  the  rarest  comphcations  of  labour,  being  only  met 
with  in  from  1  in  180,000  to  1  in  200,000  labours.  Three 
degrees  of  inversion  may  be  described  :  in  the  first  the 
placental  site — i.e.,  the  fundus — -is  depressed  so  as  to  bulge 
to  a  greater  or  less  extent  into  the  uterine  cavity  (Fig.  248,  a) ; 
in  the  second  the  fundus  protrudes  through  the  external  os 
so  as  to  enter  the  vaginal  canal  (Fig.  248,  h)  ;  in  the  third 
the  fundus  presents  at,  or  protrudes  through,  the  vulva 
(Fig.  248,  c),  the  inversion  being  complete.  It  occurs  either 
during  the  third  stage  of  labour  or  immediately  afterwards, 
but  it  is  highly  probable  that  the  process  always  commences 
during  the  third  stage,  although  it  may  not  be  recognised 
until  later. 

Causes. — Inversion  may  occur  spontaneously,  or  may  be 
induced  by  improper  methods  of  delivering  the  placenta. 
When  spontaneous  it  may  be  due  to  precipitate  labour,  but 
the  usual  cause  is  atony  of  the  wall  of  the  fundus  uteri  ;  by 
straining  efforts  on  the  part  of  the  patient  the  relaxed  area 
is  slightly  inverted,  and  the  process  then  proceeds  by  the 
active  part  of  the  uterus  contracting  upon  the  inverted  part 
and  driving  it  onwards  towards  the  cervix.  It  is  also  stated 
that  spontaneous  inversion  may  be  started  during  the  second 
stage  of  labour  by  traction  exerted  upon  the  placental  site 


INVERSION  481 

through  a  relatively  or  absolutely  short  umbilical  cord. 
(The  cord  is  said  to  be  relatively  shortened  when  coiled  round 
the  body  or  limbs  of  the  foetus.)  It  is,  however,  difficult  to 
believe  that  traction  through  the  cord  upon  the  wall  of  an 
actively  contracting  uterus  could  cause  inversion. 

Inversion  may  be  induced  during  the  third  stage  by 
endeavouring  to  deliver  the  placenta  by  pressure  on  the 
fundus  or  by  traction  on  the  cord,  when  the  uterus  is  relaxed. 
It  is  probable  that  the  process  is  merely  started  in  this  way, 
and  is  then  carried  on  spontaneously  by  uterine  contractions. 


EiG.  248. — The  Three  Degrees  of  Inversion 
of  the  Uterus.  The  Placenta  is  still 
attached  to  the  Uterine  Wall  (Sche- 
matic).    (Bumm.) 


Inversion  is  usually  produced  rapidly,  but  sometimes  appears 
to  occupy  several  days  for  its  completion. 

Symptoms. — Pain  is  a  constant  symptom.  In  the  second 
and  third  degrees  well-marked  symptoms  of  shock  also  occur, 
and  the  pain  becomes  expulsive  in  character.  There  is 
usually  haemorrhage,  but  it  is  very  variable  in  amount,  and 
seldom  profuse.  The  placenta  usually  remains  attached  to 
the  inverted  fundus  ;  when  it  has  been  detached  before 
inversion  the  risks  of  profuse  bleeding  are  much  greater. 

The  diagnosis  of  this  accident  is  not  difficult  if  the  patient 

is  seen  soon  after  it  has  occurred.     In  the  first  degree  it  may 

be  possible  to  palpate  the  fundal  depression  through  the  lax 

abdominal  walls.     When  the  fundus  has  been  expelled  into 

E.M.  31 


482  ABNORMAL   LABOUR 

the  vagiiia.  abdominal  examination  shows  that  the  body  of 
the  uterus  has  disappeared  from  its  normal  position,  and  the 
cup  formed  by  the  upper  end  of  the  inverted  organ  may 
sometimes  be  felt  with  the  fingers  ;  on  vaginal  exammation 
the  firm  round  swelling  protruding  through  the  cervix,  and 
usually  covered  by  the  placenta,  ■will  then  be  recognised 
without  difficulty  as  the  inverted  fundus.  Diagnosis  in  the 
third  degree  is  a  simple  matter  when  the  placenta  remams 
attached  ;  but  a  number  of  cases  have  been  recorded  in 
which,  the  placenta  being  detached,  the  inverted  uterus  has 
been  amputated  in  the  erroneous  belief  that  it  was  a  fibroid 
poh-pus.  Attention  to  the  abdommal  exammation  should 
prevent  this  mistake. 

The  prognosis  is  grave  ;  death  may  occur  from  htemor- 
rhage  or  from  shock,  which  may  even  prove  fatal  after  a 
reduction  of  the  displacement.  In  some  cases,  on  the  other 
hand,  the  condition  may  remam  undiscovered,  givmg  rise  to 
no  urgent  symptoms  ;  it  then  passes  into  the  phase  of  chronic 
inversion,  which  is  dealt  with  in  text-books  of  gynsecology. 

The  ireatment  consists  in  the  immediate  reduction  of  the 
displacement  by  taxis  ;  after  careful  antiseptic  preparation 
by  shaving  and  douching,  the  organ  should  be  reinverted, 
beginning  at  the  cervix,  and  gradually  returning  first 
the  cervical  part  of  the  uterus,  and  last  the  fundus.  The 
patient  is  anaesthetised,  and  one  hand  is  placed  upon  the 
abdomen  and  two  fingers  are  pressed  down  into  the  inversion 
ring  so  as  to  steady  it,  while  the  organ  is  gradually  replaced 
^^ith  the  fingers  of  the  other  hand  introduced  into  the 
vagina.  "VMien  the  displacement  has  been  completely 
returned,  a  hot  intra-uterine  antiseptic  douche  should  be 
given,  partly  for  disinfection  and  partly  to  promote  uterine 
contraction.  The  uterus  should  be  continuously  massaged 
and  ergot  administered  to  counteract  the  tendency  which 
these  cases  show  to  inertia,  and  resulting  risk  of  recurrence 
of  the  inver.sion.  Li  the  second  and  third  degrees  the 
placenta  should  be  removed  before  commencing  the 
replacement,  in  order  to  diminish  the  bulk  of  the  body  to  be 
returned  through  the  inversion  rmg  ;  this  is  unnecessary 
in  the  first  degree.  Occasionally  the  uterus  cannot  be 
returned  by  taxis  ;  hot  douches  should  then  be  used  and 
contmuous    pressure    applied    to    the    inverted    uterus    by 


ANTE-PARTUM   HEMORRHAGE  483 

packing  the  vagina  with  sterile  gauze  under  strict  antiseptic 
precautions.  After  twelve  to  twenty-four  hours  of  con- 
tinuous pressure,  taxis  may  be  repeated  and  will  probably 
prove  successful. 

Ante-partum  Haemorrhage 

By  some  writers  the  term  ante-partum  haemorrhage  is 
used  to  include  all  cases  of  haemorrhage  occurring  either  in 
connection  with  pregnancy  at  any  period,  or  in  connection 
with  the  first  and  second  stages  of  labour.  In  this  work 
haemorrhages  occurring  before  the  period  of  foetal  viability 
has  been  reached  have  been  already  dealt  with  as  Disorders 
of  Pregnancy  ;  it  is,  further,  more  convenient  from  a  clinical 
standpoint  to  restrict  the  term  ante-partum  haemorrhage  to 
cases  occurring  either  in  pregnancy  after  the  period  of 
viability  has  been  reached,  or  during  labour  before  the  birth 
of  the  child.  Slight  cases  of  ante-partum  haemorrhage, 
as  thus  defined,  may  be  due  to  such  conditions  as  fibroid 
tumours  or  malignant  disease  of  the  cervix,  and  these  con- 
ditions have  been  already  sufficiently  dealt  with.  Occasion- 
ally in  the  latter  months  of  pregnancy  profuse  haemorrhage 
may  arise  from  rupture  of  a  varicose  vein  in  the  vaginal 
wall  or  in  the  vulva.  These  cases  are,  however,  quite 
exceptional  and  as  a  rule  severe  haemorrhage  at  this  period  is 
due  to  bleeding  from  the  placental  site,  and  it  is  with  these 
cases  that  this  section  is  solely  concerned. 

Cases  of  ante-partum  haemorrhage,  as  thus  defined 
{i.e.  as  bleeding  from  the  placental  site),  are  divided 
into  two  classes,  the  basis  of  classification  being  the 
situation  of  the  placenta.  In  one  class  the  placenta 
occupies  the  normal  position — i.e.  it  is  implanted  upon  the 
uterine  wall  entirely  above  the  level  of  the  lower  uterine 
segment ;  ante-partum  haemorrhage  is  in  this  class  due  to 
premature  separation  of  the  placenta,  from  local  or  general 
disease,  or  from  traumatism.  In  the  other  class  the  placenta 
occupies  some  part  or  the  whole  of  the  lower  uterine  segment  ; 
ante-partum  haemorrhage  in  these  cases  will  necessarily  occur 
independently  of  accident  or  disease,  because  the  changes 
which  normally  take  place  in  the  lower  segment  before  and 
during  labour  inevitably  cause  the  placenta  to  be  detached 

31—2 


484 


ABNORMAL   LABOUR 


from  it.  The  former  are  known  as  cases  of  Accidental 
Hoemorrhage  ;  the  latter  as  cases  of  Placenta  Prcevia  or 
Unavoidable  Hcemorrhage.  It  must  be  borne  in  mind  that 
the  essential  difference  between  them  is  the  position  of  the 
placenta  in  the  uterus,  for  traumatism  and  disease  are  not 
limited  to  the  class  of  so-called  accidental  haemorrhage, 
but  are  quite  as  likely  to  affect  an  abnormally  situated 

placenta    as    one     nor- 
mally situated. 

Causation.  —  1.  We 
have  first  to  inquire, 
what  are  the  causes 
which  lead  to  the  im- 
plantation of  the  placenta 
in  the  lower  uterine  seg- 
ment ?  Recent  observa- 
tions have  made  it  clear 
that  there  are  two  dif- 
ferent ways  in  which  it 
may  occur  :  ( 1 )  the  fer- 
tilised ovum  may  be- 
come imbedded  in  the 
lower  part  of  the  uterus 
when  it  first  enters  this 
organ,  instead  of,  as  is 
usually  the  case,  at 
the  fundus ;  this  ex- 
j)lanation  was  com- 
monly applied  to  all 
cases  until  a  few  years 
ago  ;  (2)  after  implanta- 
tion of  the  ovum  in  the 
normal  position,  the  placenta  may  so  develop  as  to  become 
attached  in  part  to  the  lower  uterine  segment.  Cases  of  the 
first  kind  are  characterised  by  the  formation  of  the  decidua 
basahs,  wholly  or  partly,  upon  the  part  of  the  mucosa  which 
covers  the  lower  uterine  segment.  In  cases  of  the  second 
kind,  the  placenta  is  developed  in  whole  or  in  part,  in  connec- 
tion with  the  decidua  capsularis  instead  of  the  decidua  basa- 
lis ;  as  the  ovum  grows  large  enough  to  fiU  the  uterine  cavity, 
decidua  capsularis  and  decidua  vera  fuse,  and  a  part  of  the 


Fig.  249. — Basal  Placenta   Prfevia  ;    tlie 

■     -  part     of     the     Placenta     whicli    is 

attaclied     to     tlie     Lower     Uterine 

Segment    is    developed     upon     the 

Decidua  Basalis.     (Webster.) 


PLACENTA   PREVIA  485 

placenta  thus  becomes  attached  to  the  uterine  wall  over  the 
lower  segment.  The  former  may  be  conveniently  called 
basal  placenta  prcevia  and  is  shown  in  Figs.  85,  249  and  250  ; 
the  decidua  capsularis  can  be  clearly  seen  in  the  upper  part 
of  Fig.  249,  and  it  is  obvious  that  the  placenta  is  formed, 
not  upon  it,  but  upon  the  decidua  basalis.  The  latter  may 
conveniently  be  called  capsular  placenta  prcevia,  and  is  shown 


Fig.  250. — A  Gravid  Uterus  with  a  Fibroid  Tumour.     The  Placenta  is 
situated  entirely  in  the  Lower  Uterine  Segment.     (Willey.) 

in  Fig.  251 ;  here  in  a  three  months'  ovum  it  is  seen  that  the 
decidual  space  persists  and  a  portion  of  the  placenta  has 
developed  upon  the  decidua  capsularis  on  either  side  of  the 
decidua  basalis.  In  this  specimen  Webster  described  the  part 
of  the  decidua  capsularis  upon  which  placental  formation  has 
occurred  as  closely  resembling  in  vascularity  and  general 
appearance  the  decidua  basalis  adjacent  to  it.  At  a  later 
stage  of  pregnancy  a  portion  of  the  capsular  placenta  would 


486 


ABNORMAL   LABOUR 


lie  upon  the  lower  segment  and  cover  the  internal  os.  This 
part  of  the  decidua  capsularis  probably  fuses  firmly  with  the 
decidua  vera,  to  which  it  becomes  apposed  ;  accordingly, 
when  detachment  of  this  portion  of  the  placenta  occurs,  the 
plane  of  separation  will    pass  through  the  well-developed 


D .  capsularis  // 

without   placenta 


Bladder 


D.  capsularis 
with  placenta 


Junction,  of  D. capsularis 
and   D . vera 


Fig.  251. — Capsular  Placenta  Prievia,  Lateral  Variety.     From  a  Frozen 

Section.     (Clarence  "Webster.) 


cavernous  layer  of  the  decidua  capsularis,  leading  to  more 
or  less  serious  hsemorrhage. 

It  seems  probable  that  further  observation  will  show  that 
cases  of  complete  placenta  prsevia  are  always  basal ;  cases 
of  partial  or  marginal  placenta  praevia  may  be  either  basal  or 
capsular.  It  is  possible  that  some  cases  are  partly  basal  and 
partly  capsular. 

The  explanation  cannot  be  carried  further  than  this  ; 


PLACENTA   PREVIA 


487 


we  do  not  know  what  are  the  conditions  which  lead  to  the 
formation  of  a  capsular  placenta,  or  to  the  original  implan- 


FiG.  252. — Frozen  Section  of  a  Woman  who  died  of  Heemorrliage  due 
to  Placenta  Praevia.  The  cervix  is  partly  dilated,  the  placenta 
prsevia  is  lateral,  the  foetus  presents  by  the  breech.  (Barbour's 
Anatomy  of  Labour.) 

tation  of  the  ovum  upon  the  lower  part  of  the  uterine  wall 
instead  of  near  the  fundus.  Clinical  evidence  shows  that 
multiparity,  especially  when  associated  with  rapid  child- 


488  ABNORMAL   LABOUR 

bearing,  is  a  powerful  predisposing  cause  ;  there  is  a  certain 
amount  of  evidence  also  that  chronic  endometritis  and  fibroid 
tumours  may  stand  in  the  same  relation  (Figs.  85  and  250). 
It  will  be  observed  that  each  of  these  three  conditions  is  asso- 
ciated with  enlargement  of  the  uterine  cavity.  Under  normal 
conditions  the  uterine  cavity  is  potential  only  ;  when  dilated 
to  form  an  actual  cavity  it  is  obvious  that  the  fertilised  ovum 
may  descend  into  the  lower  segment  before  it  becomes 
embedded.  The  placenta  itself  is  frequently  abnormal  ; 
extensive  areas  of  degenerated  villi  may  often  be  found 
{^placental  infarcts),  and  the  cord  often  has  a  marginal  or 
velamentous  insertion.  The  nutrition  and  development  of 
the  foetus  are  unaffected. 

Given  a  low  implantation  of  the  placenta  it  is  impossible 
for  labour  to  take  place  without  haemorrhage,  for  when  the 
lower  uterine  segment  dilates  and  the  cervix  opens  during 
the  first  stage,  the  placenta  will  inevitably  become  in  part 
or  wholly  detached,  and  bleeding  will  occur  from  the 
lacerated  placental  vessels  in  the  uterine  wall  (Fig.  252). 
Hence  this  kind  of  ante-partum  haemorrhage  is  often  named 
Unavoidable  Hcemorrhage.  But  the  low  position  of  the 
placenta  is  not  the  only  possible  cause  of  haemorrhage  in 
such  cases,  for  traumatism  or  local  disease,  such  as  will  be 
described  in  the  next  joaragraph,  may  affect  a  placenta 
prsevia,  and,  by  causing  partial  detachment,  may  lead  to 
haemorrhage. 

2.  With  regard  to  accidental  hcemorrhage  considerable 
uncertainty  still  exists  as  to  the  relative  importance  of 
injury  and  disease  in  causmg  separation  of  the  normally 
situated  placenta.  Instances  are  rare  in  which  it  can  be 
attributed  solely  to  direct  injury — e.g.  a  kick  on  the  abdomen 
or  a  fall ;  but  there  is  no  doubt  that  such  injuries  may  cause 
separation  of  a  healthy  placenta  from  its  normal  attach- 
ments. It  is  probable  that  a  sudden  rise  in  intra-abdominal 
pressure,  produced  for  instance  by  an  unusual  muscular 
effort  or  severe  coughing  or  vomiting,  may  detach  the 
placenta,  when  local  disease  weakening  its  attachments 
exists,  and  therefore  in  these  cases  both  injury  and  disease 
are  factors  in  causation.  In  other  cases  the  haemorrhage  is 
absolutely  spontaneous  and  must  be  attributed  solely  to 
disease.     It  is  somewhat  of  a  reproach  to  obstetrics  that 


ACCIDENTAL   HEMORRHAGE  489 

current  knowledge  of  the  nature  of  the  diseases  which  cause 
accidental  haemorrhage  is  so  unsatisfactory  and  incomplete. 
The  most  that  can  be  said  is  that,  upon  evidence  not  always 
convincing,  the  following  are  believed  to  be  the  most 
important  : 

Chronic  Bright 's  disease. 

Anaemia. 

Purpura. 

Syphilis. 

Cardiac  disease  (especially  mitral  lesions). 

Fibroid  tumours  of  the  uterus  (when  submucous  or 
interstitial). 

Decidual  endometritis. 

It  must  be  admitted  that,  except  in  the  case  of  chronic 
nephritis,  the  evidence  that  these  conditions  alone  can  cause 
accidental  haemorrhage  is  inconclusive.  Histological  exami- 
nation of  the  uterine  wall  after  death,  or  better  after  its 
removal  by  operation,  has  so  far  failed  to  reveal  any 
structural  changes  to  which  the  haemorrhage  may  be  attri- 
buted. In  cases  of  concealed  accidental  haemorrhage 
interstitial  bleeding  has  been  found  in  the  muscular  wall, 
but  this  is  probably  the  result  of  over-distension  of  the 
organ  and  is  not  related  to  the  original  haemorrhage  from 
the  placental  site.  It  has  also  been  suggested  that  a 
very  short  cord  may  be  the  cause  of  haemorrhage  during 
the  second  stage  of  labour,  from  traction  on  the  placenta. 
It  is  believed  that  nervous  shock  may  initiate  it  by 
exciting  a  sudden  and  violent  uterine  contraction,  suffi- 
ciently powerful  to  cause  slight  separation  of  the  placenta. 
Multiparity  is  a  powerful  predisposing  cause,  and  the 
great  majority  of  cases  occur  in  feeble  and  debilitated 
women.  It  is  accordingly  much  commoner  in  hospitals 
than  in  private  practice. 

3.  The  question  next  arises,  why  does  ante-partum 
haemorrhage  always  occur  when  the  placenta  invades  the 
lower  uterine  segment,  and  not  when  it  occupies  the  normal 
situation  ?  The  answer  will  be  found  in  the  different 
functions  of  the  upper  and  lower  parts  of  the  body  of  the 
uterus.  The  upper  part  plays  an  active  role  in  labour, 
undergoing  intermittent  contractions,  and  progressive  and 
continuous  retraction.     The  attachment  of  the  placenta  to 


490  ABNORMAL  LABOUR 

this  part  of  the  uterine  wall  is  not  affected  by  the  normal 
contractions  of  the  first  and  second  stages,  for  although  these 
doubtless  entail  a  slight  diminution  in  the  superficies  of  the 
uterine  wall,  this  diminution  is  not  sufficient  to  disturb  the 
placental  attachments.  Retraction  causes  more  extensive 
reduction  of  the  superficies  of  the  uterine  wall,  but  until  the 
body  of  the  foetus  has  been  expelled  retraction  is  only  shght 
in  normal  labour,  and  therefore  the  placenta  is  able  to  main- 
tain its  attachments.  The  lower  part  of  the  uterus,  on  the 
other  hand,  plays  a  passive  role  ;  no  contractions  occur  in 
it,  but  it  gradually  becomes  stretched  during  the  stage  of 
dilatation  so  that  its  superficial  area  is  greatly  increased,  and 
its  shape  altered  from  that  of  a  section  of  a  hemisphere  to 
that  of  a  cylinder.  The  placenta  is  unable  to  expand  in 
correspondence  with  the  stretchmg  of  its  site  of  attachment, 
and  the  consequence  is  that  the  uterine  wall  becomes 
progressively  torn  away  from  the  placenta,  and  haemor- 
rhage then  occurs  from  lacerated  utero-placental  vessels. 
Haemorrhage  is,  accordmgly,  said  to  be  unavoidable  in 
placenta  praevia. 

But  how  can  we  account  for  the  occurrence  of  bleedmg 
before  the  onset  of  labour,  in  cases  of  placenta  praevia  1  It  is 
possible  that,  in  a  certain  proportion,  disease  of  the  placenta 
or  traumatism — direct  or  indirect — may  explain  it.  Li 
may  cases,  however,  the  bleeding  appears  to  be  due  solely 
to  the  abnormal  situation  of  the  placenta.  A  physiological 
explanation  of  these  cases  has  been  suggested  by  Pinard — 
viz.  that  during  the  last  few  weeks  of  pregnancy  the  inter- 
mittent uterine  contractions  become  gradually  stronger 
(they  are  certainly  more  easily  palpable),  although  they 
remain  painless  and  unperceived  by  the  mother.  Upon  the 
lower  segment  these  contractions  exercise  a  dilating  force, 
which  may  be  sufficient  to  cause  slight  separation  of  the 
placenta  and  more  or  less  profuse  haemorrhage.  In  support 
of  this  explanation  may  be  cited  the  clinical  fact  that  a 
degree  of  dilatation  of  the  internal  os  sufficient  to  admit  one 
finger  is  met  with  in  the  last  few  weeks  of  pregnancy, 
frequently  in  multiparae,  occasionally  in  primigravidae. 
Webster  has  suggested  an  anatomical  explanation — viz.  that 
when  haemorrhage  occurs  before  term  we  have  to  do  with  a 
capsular    placenta    prcevia,    in    which    the   fusion    between 


PLACENTA   PRiEVIA 


491 


decidua  vera  and  decidua  capsularis  has  not  been  very  firm  ; 
hence  separation  of  the  two  decidual  layers  readily  occurs, 
leading  to  haemorrhage. 

Morbid  Anatomy. — 1.  Placenta  prcBvia. — The  extent  of 
the  area  which  the  placenta  occupies  in  the  lower  seg- 
ment varies,  and  three 
degrees  are  accordingly 
distinguished  :  (1)  The 
placenta  may  occupy 
the  whole  of  the  lower 
segment,  its  centre 
being  situated  approxi- 
mately over  the  inter- 
nal OS  ;  this  is  called 
central  placenta  proevia 
(Figs.  250  and  253).  In 
clinical  practice,  cases 
are  called  central  in 
which  the  placenta 
completely  covers  the 
OS  and  the  margin  can- 
not be  reached  by  the 
finger.  (2)  It  may 
occupy  approximately 
one-half  of  the  lower 
segment,  the  placenta 
covering  the  undilated 
internal  os  ;  this  is 
called  lateral  placenta 
prcevia  (Figs.  252  and 
254).  (3)  It  may  be 
attached  only  to  the 
upper  part  of  the 
lower  segment  on  one 
side,  so  as  to  lie  com- 
pletely above  the  level  of  the  internal  os ;  this  is  called  marginal 
placenta  prcevia  (Fig.  251).  It  will  be  obvious  that  in  each 
variety  the  placenta  to  a  greater  or  less  extent  also  overlaps 
the  safe  zone — i.e.  the  uterine  wall  above  the  upper  limit  of 
the  lower  segment.  The  amount  of  haemorrhage  met  with 
depends  mainly,  if  not  entirely,  upon  the  extent  of  placental 


Fig.  253.- — -Central  Placenta  Prcevia  ;  the 
Placenta  occupies  the  whole  of  tlie 
Lower  Uterine  Segment.     (Butxim.) 


492 


ABNORMAL   LABOUR 


site  which  is  laid  bare  in  the  process  of  dilatation  ;  accord- 
ingly there  will  generally  be  the  greatest  amount  with 
central,  the  least  mth  marginal,  placenta  prsevia.  And 
further,  inasmuch  as  the  central  variety  offers  a  mechanical 
obstacle  both  to  the  expulsion  of  the  foetus   and  to  the 


Umbilical  cord 


Placenta 


Uterine  -wall 


DetacKedl 
placenta 


Fig.  254. — Lateral    Placenta    Prfevia;    the   Placenta   overlaps    the   Os 
Internum,    which    is    partly    dilated.      From    a    Frozen    Section. 

(Ahlfeld.) 

performance  of  any  intra-uterine  operation,  it  is  the  most 
difficult  to  deal  with. 

From  clinical  evidence  there  is  reason  to  believe  that  the 
wall  of  the  lower  segment  is  unusually  weak  and  friable  when 
the  placenta  is  inserted  upon  it  ;  no  abnormal  thinning  has 
been  detected  in  frozen  sections  (Fig.  252),  but  the  develop- 


ACCIDENTAL   HEMORRHAGE 


493 


ment  in  it  of  the  large  sub-placental  venous  sinuses  probably 
lessens  the  resisting  power  of  the  uterine  wall.     The  practical 


lj/lf,'lll/l  Adherent 
-  fragment 
of  decid.ua, 


Blood  escaping 
from  cervix 

Fig.  255. — Concealed  Accidental  Hsemorrliage. 
(Varnier.) 

result  is  that  rupture  of  the  lower  segment  is  very  readily 
caused  by  intra-uterine  manipulations. 

2.  Accidental  Hcemorrhage. — It  is  rarely  the  case  that  the 
entire  placenta  is  separated  from  the  uterine  wall  in  acci- 
dental haemorrhage,  although  this  occurrence  is  shown  (from. 


494  ABNORMAL   LABOUR 

nature)  in  Fig.  255  ;  here  a  very  large  effusion  was  formed 
behind  the  placenta,  which  resulted  in  the  death  of  the 
patient  from  internal  haemorrhage.  Separation  of  a  portion 
only  of  the  placenta  is,  however,  quite  enough  to  cause  very 
severe  bleeding.  Usually  the  effused  blood  escapes  under 
the  placental  margin  and  makes  its  way  between  the  mem- 
branes and  the  uterine  wall  down  to  the  internal  os,  whence 
it  passes  through  the  cervix  into  the  vagina.  If  the  haemor- 
rhage is  accompanied  by  labour  pains,  this  will  invariably 
occur,  the  effused  blood  being  expelled  from  the  uterus  by 
the  contractions. 

It  is,  however,  not  uncommon  for  retention  of  blood 
within  the  uterus  to  occur  during  accidental  hsemorrhage, 
and  it  will  be  generally  observed  that  a  considerable  mass  of 
blood-clot  accompanies  or  immediately  follows  the  expulsion 
of  the  placenta  in  a  case  of  free  external  bleeding.  In  very 
rare  instances,  however,  almost  the  whole  of  the  effused 
blood  is  thus  retained,  leading  to  the  condition  known 
clinically  as  concealed  accidental  hcemorrhage.  The  most 
important  cause  of  this  retention  is  probably  weakness,  loss 
of  tone,  or  loss  of  excitability  of  the  uterine  muscle,  which 
results  in  complete  absence  of  uterine  contractions.  Accord- 
ingly the  uterus  distends  easily  to  accommodate  the  effused 
blood,  and  in  time  the  muscle  becomes  completely  paralysed 
from  great  over-distension,  and  unable  to  respond  to  any 
stimulus  whatever.  Other  conditions  may  favour  the 
occurrence  of  concealed  haemorrhage,  such  as  (1)  morbid 
adhesion  of  the  placental  margin,  leading  to  the  formation 
of  retro-placental  hsematoma  ;  (2)  morbid  adhesion  of  the 
membranes  around  the  internal  os,  preventing  the  blood 
from  entering  the  cervical  canal.  Sometimes,  in  concealed 
haemorrhage,  the  amnion  is  ruptured  by  the  effused  blood, 
so  that  bleeding  takes  place  into  the  amniotic  sac  ;  more, 
often  it  is  found  between  the  placenta  or  membranes  and  the 
uterine  wall.  There  is  usually  a  little  external  bleeding  in 
concealed  accidental  haemorrhage  (Fig.  255).  In  placenta 
praevia  there  is  no  concealed  bleeding. 

It  will  be  clear  from  the  above  that,  in  addition  to 
external  and  concealed  accidental  haemorrhage,  a  third 
variety,  partly  external  and  partly  concealed,  may  be 
described. 


ANTE-PARTUM  HEMORRHAGE  495 

Symptoms  and  Influence  upon  Labour. — 1.  There  is  onty 
one  symptom  of  placenta  proevia — viz.  visible  haemorrhage. 
This  symptom  may  make  its  appearance  in  pregnancy,  but 
seldom  before  the  twenty-eighth  or  thirtieth  week,  up  to 
which  period  nothing  occurs  to  indicate  the  existence  of  the 
abnormality.  There  is  no  doubt  that  many  cases  of  abor- 
tion occurring  between  the  formation  of  the  placenta  and 
the  period  of  foetal  viability  may  be  due  to  placenta  prsevia. 
In  these  cases,  however,  the  treatment  is  simply  that  of 
any  abortion  ;  the  position  occupied  by  the  placenta 
cannot  be  clinically  recognised,  and  does  not  influence  the 
question  of  management.  From  a  practical  standpoint 
they  therefore  belong  to  a  different  class  from  that  now  under 
consideration.  If  a  placenta  prsevia  successfully  passes  the 
fourth  month,  there  is  apparently  little  tendency  to  further 
haemorrhage  until  the  twenty-eighth  week  is  reached.  The 
bleeding  is  not  accompanied  by  pain,  unless  labour  starts 
simultaneously  ;  the  effused  blood  is  arterial  and  may  be 
profuse  in  quantity.  The  onset  is  usually  spontaneous,  and 
often  occurs  during  sleep  ;  but,  as  already  explained,  a 
history  of  traumatism  may  be  met  with.  The  first  attack 
may  cease  spontaneously  in  a  few  hours,  but  there  is  a 
marked  tendency  to  recurrence,  and  by  repeated  haemor- 
rhages at  intervals,  the  patient  may  become  exsanguine 
before  labour  sets  in. 

The  general  course  of  labour  is  unfavourably  affected 
by  placenta  praevia  as  follows  :  (1)  Labour  is  usually  prema- 
ture,  and  as  the  capacity  of  the  lower  uterine  segment  is 
diminished,  the  presentation  is  frequently  abnormal  ;  in 
352  cases  recorded  by  Biirger  and  Graf  the  presentations 
were — vertex  69 '2  per  cent.,  transverse  2ri  per  cent, 
breech  (all  varieties)  9'4  per  cent.,  but  the  proportion  of 
transverse  presentation  in  this  series  is  probably  urmsually 
high  ;  (2)  the  stage  of  dilatation  is  prolonged  owing  to  the 
deficient  formation  or  entire  absence  (in  central  cases)  of 
the  natural  dilator — the  bag  of  waters  ;  (3)  when  the  haemor- 
rhage is  severe,  uterine  exhaustion  (secondary  inertia)  may 
set  in  ;  (4)  interference  is  frequently  required  to  arrest  the 
bleeding  temporarily  or  to  terminate  labour  rapidly  ; 
(5)  consequently  there  is  increased  risk  of  serious  laceration 
of  the  cervix  and  lower  uterine  segment ;     (6)  puerperal 


496  ABNORMAL   LABOUR 

septic  infection  is  a  relatively  frequent  sequel,  being 
accounted  for  partly  by  the  frequency  of  operative  inter- 
ference and  of  serious  cervical  tears,  and  partly,  as  is  well 
recognised  from  diminution  in  the  patient's  powers  of 
resistance  to  infective  ]3i'ocesses,  brought  about  by  loss  of 
blood  ;  (7)  the  life  of  the  foetus  is  jeopardised  by  premature 
separation  of  the  placenta,  which  may  cause  asphyxia 
(p.  633),  by  prolapse  of  the  cord,  or  by  the  interference 
required  to  terminate  labour. 

During  the  first  stage  of  labour  haemorrhage  proceeds 
either  continuously  or  in  irregular  gushes  ;  or  the  vagina 
may  become  filled  up  with  masses  of  blood-clot.  Towards 
the  end  of  this  stage  the  haemorrhage  abates,  because  the 
presenting  part  compresses  the  placental  site  in  passing 
through  the  dilated  lower  segment.  After  the  expulsion  of 
the  body  the  placenta  becomes  completely  detached,  and  is 
usually  expelled  immediately  after  the  child.  Unless 
secondary  uterine  inertia  sets  in,  the  bleeding  then  ceases. 

2.  Accidental  hcemorrhage  is  characterised  either  by 
external  bleeding  or  by  the  signs  and  sjrmptoms  of  concealed 
uterine  licemorrJiage.  It  is  probable  that  many  cases  of 
abortion  occurring  after  the  third  month  are  due  to  detach- 
ment, by  traumatism  or  disease,  of  the  normally  situated 
placenta,  and  these  are  technically  cases  of  accidental 
haemorrhage.  It  is,  however,  convenient,  as  already  ex- 
plained, to  restrict  this  term  to  cases  occurrmg  after  the 
period  of  viabihty  of  the  foetus  has  been  attamed.  It  is 
therefore  obvious  that  in  cases  of  accidental  haemorrhage, 
Tvdth  external  bleeding  coming  on  durmg  the  seventh  or 
eighth  month,  the  symptoms  mil  closely  resemble  those  of 
placenta  praevia.  Even  if  a  history  of  traumatism  is 
obtained,  it  does  not  necessarily  follow  that  the  case  is  one 
of  accidental  haemorrhage  ;  the  diiferential  diagnosis  can 
only  be  made  in  the  manner  to  be  described  later  on. 

In  concealed  accidental  haemorrhage  we  have  one  of  the 
most  serious  accidents  that  can  possibly  happen  to  a  preg- 
nant woman.  In  a  severe  case  there  is  a  fairly  characteristic 
train  of  signs  and  symptoms,  which  are  due  to  two  factors  : 
(1)  Loss  of  blood,  (2)  over-distension  of  the  uterus.  The 
general  symptoms  caused  by  internal  bleeding  have  been 
referred  to  in  connection  with  tubal  pregnancy  (p.  190),  and 


ANTE-PARTUM   HAEMORRHAGE  497 

need  not  be  described  again.  The  occurrence  of  minor 
degrees  of  concealed  haemorrhage  may  sometimes  be  diag- 
nosed by  noting,  in  an  apparent  case  of  external  haemorrhage, 
that  the  degree  of  constitutional  disturbance  is  dispropor- 
tionate to  the  amount  of  blood  lost.  In  a  severe  case  of 
concealed  bleeding  the  constitutional  disturbance  is  pro- 
found. Over-distension  of  the  uterus  causes  severe,  con- 
tinuous, and  increasing  abdominal  pain,  combined  with 
shock.  The  uterus  itself  increases  rapidly  in  size,  and  in  a 
few  hours  may  become  large  enough  to  displace  the  dia- 
phragm and  embarrass  the  respiration.  On  examination 
per  abdomen  it  will  be  observed  that  the  uterus  is  unduly 
large,  and  tender,  and  sometimes  so  tense  as  to  feel  almost 
wooden  in  consistence  ;  no  contractions  can  be  made  out  ; 
the  foetal  parts  cannot  be  detected  nor  the  sounds  of  the 
foetal  heart  heard.  If  progressive  increase  in  size  of  the 
uterus,  in  the  course  of  a  few  hours,  can  also  be  made  out, 
the  presence  of  concealed  bleeding  is  certain.  On  vaginal 
examination  a  little  bleeding  from  the  uterus  will  usually  be 
detected,  although  in  rare  cases  there  is  none.  The  tem- 
perature will  be  subnormal,  the  pulse  will  be  rapid — over  120 ; 
there  will  be  pallor,  or  absolute  blanching  of  the  skin  and 
mucous  membranes. 

Concealed  accidental  haemorrhage  is  invariably  accom- 
panied by  complete  paralysis  of  the  uterine  muscle  ;  the 
cervix  is  usually  undilated,  and  not  only  are  there  no  spon- 
taneous uterine  contractions,  but  it  is  extremely  difficult  to 
obtain  any  response  to  the  ordinary  methods  of  excitation. 

Clearly  a  certain  resemblance  exists  between  this  condi- 
tion and  tonic  uterine  contraction  (see  p.  449).  In  concealed 
haemorrhage,  however,  the  uterus  is  larger  than  normal,  but 
in  tonic  contraction  it  is  much  smaller  ;  and  while  signs  of 
internal  haemorrhage  are  conspicuous  in  the  former,  in  the 
latter  the  signs  are  those  of  '  obstetric  exhaustion  '  with 
some  rise  of  temperature.  Lastly,  in  tonic  contraction  the 
cervix  is  always  considerably  dilated,  and  the  presenting 
part  impacted,  while  in  concealed  haemorrhage  the  cervix  is 
small  and  the  presentation  obscure.  Accordingly,  errors  in 
diagnosis  need  hot  occur. 

In  external  accidental  haemorrhage  the  course  of  labour  is 
unfavourably  affected,  in  very  much  the  same  manner  as  in 
s.M.  32 


498  abxor:\l.\l  labour 

placenta  praevia.  But  mucli  greater  variation  in  the  amount 
of  lisemorrhage  is  met  ^Wth  in  the  former  than  in  the  latter  ; 
many  cases  of  accidental  haemorrhage  are  trivial,  but 
placenta  praevia  is  nearly  always  serious.  Labour  is  usually 
premature  ;  tedious  from  partial  uterine  inertia  ;  dangerous 
to  the  mother  on  account  of  loss  of  blood,  and  on  account  of 
the  frequent  necessity  for  operative  interference  increasing 
the  risks  of  sepsis  ;  dangerous  to  the  child  from  risks  of 
asphyxia  by  premature  separation  of  the  placenta,  or  of 
injury  during  intra-uterine  operations.  Generally  speaking 
accidental  haemorrhage  does  not  show  the  same  tendency  to 
recurrence  as  placenta  praevia.  Although  recurrences  either 
before  labour  or  when  labour  sets  in  are  common,  they  are 
by  no  means  invariable,  as  in  the  case  of  placenta  praevia. 
Cases  are  accordingly  not  infrequent,  in  which,  after  a  single 
shght  or  moderate  bleeding  of  the  accidental  type,  pregnancy 
is  completed  and  labour  brought  to  a  close  without  further 
haemorrhage. 

Differential  Diagnosis. — The  differential  diagnosis  be- 
tween placenta  praevia  and  accidental  haemorrhage  can  only 
be  made  by  recognising  in  the  former  that  the  placenta 
occupies  the  lower  uterine  segment.  It  is  said  that  this  may 
sometimes  be  done  by  palpation  and  auscultation  per  abdo- 
men, but  this  is  doubtful.  ^^Tien  the  cervix  is  closed  it  may 
be  surmised  that  the  placenta  occupies  the  lower  segment 
from  the  consistence  of  the  uterine  wall  as  felt  through  the 
vaginal  fornices  ;  an  unusual  extent  of  soft  boggy  resistance 
may  here  be  felt,  obscuring  the  presenting  part,  and  making 
the  detection  of  ballottement  difficult.  The  presence  of  the 
placenta  in  the  lower  segment  interferes  with  the  descent  of 
the  presenting  part,  and  renders  engagement  of  the  head  in 
the  brim  before  labour  impracticable.  Jl,  therefore,  the 
head  is  fomid  engaged,  the  case  is  more  likely  to  be  one  of 
accidental  hfemorrhage. 

The  only  conclusive  method  is  to  pass  the  finger  through 
the  internal  os,  when  the  placenta  can  be  recognised  by  direct 
touch.  If  the  edge  of  the  placenta  is  within  reach  its  recog- 
nition by  the  fhiger  is  fairly  easy,  from  its  rounded  contour 
and  the  sharp  line  of  transference  from  placenta  to  mem- 
branes. WTien  the  edge  cainiot  be  reached  a  httle  care  is 
required  to  distmguish  retamed  blood-clot  from  placental 


ANTE-PARTUM   HxEMORRHAGE  499 

tissue,  the  much  greater  friabihty  of  the  former  bemg  the 
chief  point  of  distinction  between  them.  This  method  is,  of 
course,  only  apphcable  when  the  internal  os  has  begun  to 
dilate  ;  but  after  a  severe  haemorrhage  there  is  usually 
sufficient  dilatation  for  the  diagnosis  to  be  made  in  this 
manner  ;  during  labour  no  difficulty  will  be  encountered 
except  in  marginal  cases  early  in  labour,  when  the  placental 
edge  may  lie  so  far  away  from  the  os  as  to  be  beyond  the 
reach  of  the  finger.  When  the  placenta  cannot  be  felt  in 
the  lower  segment  the  case  must  be  regarded  as  one  of 
accidental  haemorrhage.  Cases  of  concealed  haemorrhage 
are  never  due  to  placenta  praevia. 

Treatment  before  Labour. — Before  labour,  slight  cases  of 
accidental  hoemorrhage  should  in  the  first  place  be  treated 
by  palliative  measures.  Complete  rest  in  bed  should  be 
enforced,  and  continued  for  at  least  a  week  after  all  bleeding 
has  ceased  ;  a  daily  aperient,  and  light  diet  without  stimu- 
lants, should  be  enjoined.  Sedatives  will  be  indicated  in 
most  cases,  some  form  of  opium  being  undoubtedly  the  most 
useful.  Ergot  has  been  advised  in  small  doses — 10  to  20 
minims  of  Uquid  extract  three  times  a  day  ;  but  it  is  very 
doubtful  whether  it  exerts  any  appreciable  effect.  A  hypo- 
dermic injection  of  J  grain  of  morphia  may  be  given  in  the 
first  instance,  and  repeated  in  doses  of  I  grain  if  the  bleeding 
continues.  In  cases  where  the  amount  of  external  loss  is 
slight,  a  careful  watch  should  be  kept  for  the  signs  of 
concealed  bleeding.  Recurrence  of  bleeding  does  not 
necessarily  take  place,  and  even  when  labour  occurs  there 
may  be  no  more  haemorrhage.  Palliative  treatment  should 
not  be  continued  for  more  than  twenty-four  hours,  when  it 
fails  to  control  bleeding.  After  a  single  severe  haemorrhage, 
labour  usually  sets  in  spontaneously,  unless  the  uterine 
muscle  becomes  paralysed  from  over-distension. 

In  the  case  of  placenta  prcevia,  the  same  line  of  treatment 
should  not  be  adopted  unless  the  patient  can  be  kept  under 
continuous  observation,  and  assistance  is  available  in  the 
event  of  a  serious  recurrence  of  bleeding.  Otherwise,  labour 
should  be  at  once  induced,  even  after  a  single  haemorrhage, 
for  in  placenta  praevia  the  recurrence  of  bleeding  either 
before  or  during  labour  is  inevitable,  while  in  accidental 
haemorrhage  it  is  not.     The  best  method  of  induction  is 

32—2 


500  ABNORMAL   LABOUR 

the  use  of  de  Ribes'  bag,  with  version  later  on  if  necessary 
{vide  infra). 

Management  of  Labour. — The  management  of  labour 
complicated  by  ante-partum  haemorrhage  must  be  guided  by 
the  following  principles  :  (1)  In  all  severe  cases  the  imme- 
diate indication  is  to  control  the  bleeding,  and  then  to  delay 
delivery  until  there  has  been  time  for  the  patient  to  recover 
from  the  shock  of  a  severe  haemorrhage,  and  for  the 
labour  to  make  progress  ;  (2)  permanent  arrest  of  the 
haemorrhage  can,  however,  only  be  ensured  by  complete 
evacuation  and  retraction  of  the  uterus  ;  therefore  the  risk  of 
recurrence  will  continue  until  delivery  has  been  completed  ; 
(3)  in  urgent  cases  the  chances  of  the  child  surviving  are  so 
slight  that  treatment  may  be  directed  solely  to  the  interests 
of  the  mother. 

Temporary  arrest  of  hcemorrhage  is  much  more  practicable 
in  placenta  praevia  than  in  accidental  haemorrhage  ;  in  the 
former  the  placental  site  in  the  lower  uterine  segment  is 
accessible  from  the  vagina,  and  may  be  subjected  to  direct 
compression  in  various  ways  ;  in  the  latter  the  placental  site 
cannot  be  localised  and  is  inaccessible  to  direct  compression. 
The  effect  of  uterine  contractions  in  the  two  cases  is  also 
different  :  in  placenta  praevia  the  lower  segment  is  progres- 
sively dilated  and  the  placental  site  progressively  denuded 
by  the  uterine  contractions,  which  accordingly  tend  to 
increase  the  bleeding,  until  that  part  of  the  placenta  which 
occupies  the  lower  segment  is  comj)letely  detached  ;  in 
accidental  haemorrhage  each  contraction  temporarily 
diminishes  the  maternal  blood-flow  to  the  placental  site,  and 
accordingly  tends  for  the  moment  to  check  bleeding.  Uterine 
contractions  are,  in  point  of  fact,  the  only  means  we  possess 
of  temporarily  controlling  accidental  haemorrhage,  and  treat- 
ment is  therefore  directed  to  exciting  them  to  the  greatest 
possible  activity.  In  both  varieties  of  ante-partum  haemor- 
rhage, elevating  the  foot  of  the  bed  for  10  to  12  inches  is 
believed  to  check  the  bleeding  slightly  and  is  usually 
practised. 

Treatment  of  Severe  Cases  of  Placenta  Praevia, — In 
practically  all  cases  of  placenta  praevia  in  which  considerable 
bleeding  has  occurred,  whether  in  labour  or  not,  the  cervix 
will  be  found  to  be  sufficiently  dilated  to  admit  one  finger  or 


ANTE-PARTUM   HEMORRHAGE  501 

sometimes  two  fingers.  Two  methods  of  treatment  are  then 
available,  either  of  which  will  immediately  arrest  bleeding  by 
compressing  the  placental  site,  and  will  also,  after  an  interval, 
excite  labour.  These  methods  are  {a)  pulling  down  a  leg  so 
as  to  plug  the  lower  uterine  segment  and  cervix  with  the 
half -breech  ;  (6)  introducing  the  hydrostatic  dilator  of 
de  Ribes  into  the  uterus  so  as  to  produce  the  same  effects. 
Each  of  these  methods  has  advantages  in  some  respects  over 
the  other,  and  opinion  is  accordingly  divided  as  to  which 
should  have  the  preference.  It  will  be  convenient  first  to 
describe  these  methods  and  then  compare  them  as  to  their 
merits. 

(A.)  Pulling  dotvn  a  Leg. — If  the  presentation  is  vertex 
or  transverse,  the  foetus  must  be  turned  in  order  to  allow  of 
the  leg  being  brought  down  within  reach  of  the  fingers  passed 
into  the  cervix.  As  it  is  very  desirable  to  avoid  unnecessary 
internal  manipulations,  version  should  be  performed  by  the 
external  method  if  possible  (p.  672)  ;  under  anaesthesia  this 
can  usually  be  done,  even  when  labour  is  in  progress,  if  the 
membranes  have  not  ruptured,  and  an  anaesthetic  will  in  all 
cases  be  required  in  order  to  pass  the  fingers  through  the 
cervix.  A  pelvic  presentation  having  thus  been  produced, 
the  vulva  should  first  be  shaved,  afterwards  the  vulva  and 
vaginal  canal  should  be  thoroughly  swabbed  first  with  ether 
soap  and  then  with  a  reliable  antiseptic,  such  as  lysol 
(a  teaspoonful  to  a  pint),  or,  as  an  alternative,  dried 
with  sterile  swabs  and  then  freely  painted  over  with 
tincture  of  iodine.  The  operator  should  also  wear  sterilised 
rubber  gloves.  The  most  stringent  antiseptic  precautions 
are  called  for,  as  the  denuded  portion  of  the  placental 
site,  with  its  large  open  vessels,  is  within  the  area 
of  the  manipulations,  thus  favouring  direct  absorp- 
tion into  the  circulation,  and  tending  to  make  the  results  of 
even  slight  degrees  of  infection  very  serious.  Bi-polar 
combined  version  should  therefore  be  avoided  whenever  the 
foetus  can  be  turned  by  the  external  method.  When  the 
breech  has  been  brought  over  the  pelvic  brim  it  is  usually 
easy  to  find  a  foot,  if  two  fingers  can  be  passed  into  the  cervix  ; 
the  only  difficult  cases  are  those  of  central  insertion,  when 
the  placental  tissue  over  the  os  must  be  first  torn  through 
with  the  finger.     The  membranes  should  then  be  ruptured, 


502 


ABNORMAL   LABOUR 


and  the  foot  seized  by  the  anMe  and  pulled  down  into  the 
vagina.  If  the  legs  should  be  extended  and  the  feet  con- 
sequently out  of  reach,  it  is  impossible  at  this  stage  of  labour 


Tom  utero-placental 

vessels  in  placental 

site 


Fig.  256. — Placenta  Prsevia ;  Lower  Uterine  Segment  and  Cervix 
Plugged  by  the  Half -Breech.     (Bumm.) 


to  pull  down  a  leg  at  all,  and  the  alternative  method  of 
treatment  by  de  Ribes'  bag  must  be  adopted. 

A  certain  amount  of  fresh  bleeding  is  necessarily  caused 
by  these  manipulations,  but  by  exerting  gentle  continuous 
traction  on  the  foot  the  half -breech  may  be  pulled  down  into 
the  lower  uterine  segment  (Fig.  256)  so  as  to  plug  it  firmly  and 
directly  to  compress  the  placental  site.     A  degree  of  traction 


ANTE-PARTUM   HAEMORRHAGE  503 

just  sufficient  to  arrest  bleeding  may  be  kept  up  steadily  by 
an  assistant  by  means  of  a  tape  tied  to  the  foot  ;  very  little 
exercise  of  force  is  required  to  prevent  further  hsemorrhage, 
and  great  gentleness  is  called  for  because  (1)  it  is  not  desirable 
to  hurry  the  delivery  of  the  child  ;  (2)  serious  laceration  of 
the  cervix  running  up  into  the  lower  segment  and  involving 
the  placental  sinuses  is  very  readily  caused,  which  may  result 
in  troublesome  post-partum  hsemorrhage,  and  which  increases 
the  risks  of  sepsis.  Continuous  traction  may  be  applied  by 
attaching  a  weight  of  1  to  2  pounds  to  the  foot-tape,  but 
mechanical  methods  are  inferior  to  traction  by  an  assistant, 
as  the  latter  can  be  regulated  with  nicety  to  the  minimum 
force  required  to  stop  bleeding. 

After  a  leg  has  been  pulled  down  it  is  essential  that  an 
interval  should  be  allowed  to  elapse  before  delivery,  if  there 
has  been  serious  bleeding  ;  profuse  hsemorrhage  is  not  an 
indication  for  rapid  delivery  in  placenta  prsevia,  for  the 
shock  induced  by  rapidly  emptying  the  uterus  may  prove 
fatal  to  patients  already  suffering  from  the  constitutional 
effects  of  hsemorrhage.  When  this  procedure  is  adopted  in 
cases  not  actually  in  labour,  effective  labour  pains  usually 
begin  within  twelve  hours  ;  there  is  no  more  powerful  or 
certain  method  of  exciting  active  uterine  contractions.  If 
labour  has  already  begun  the  process  will  be  expedited,  but 
the  expulsion  of  the  body  of  the  child  should  be  left  entirely 
to  the  natural  forces,  and  no  attempt  made  to  deliver  by 
traction.  It  will  be  recollected  that  the  same  rule  has 
been  already  laid  down  for  ordinary  breech  labour,  on 
account  of  the  increased  risks  of  extension  of  the  arms  or 
head  occurring  when  traction  is  made.  In  the  case  of 
placenta  prsevia  the  additional  object  of  delay  is  to  allow 
time  for  recovery  from  shock  and  hsemorrhage,  and  for  the 
application  of  restorative  measures  to  the  mother.  In 
severe  cases  the  same  restorative  methods  may  be  employed 
as  in  bad  cases  of  post-partum  hsemorrhage  (p.  525). 

When  labour  pains  become  effective  and  the  body  of  the 
child  is  gradually  expelled,  no  further  serious  bleeding  will 
occur,  for  the  trunk  and  head  of  the  child  successively  plug 
the  lower  segment  and  compress  the  placental  site.  As  soon 
as  the  child  has  been  delivered,  the  third  stage  should  be 
completed  as  rapidly  as  possible,  for  post-partum  hsemor- 


504  ABNORMAL   LABOUR 

rhage  frequently  occurs  from  imperfect  retraction,  and  when 
there  have  already  been  profuse  losses  of  blood  even  a 
moderate  amount  of  post-partum  bleeding  may  prove  fatal. 
Therefore  the  placenta  should  be  at  once  expressed,  or  if  this 
cannot  be  done  it  should  be  digitally  removed.  As  a  rule, 
expression  is  easy  because  the  placenta  has  already  been 
extensively  detached.  An  antiseptic  intra-uterine  douche 
should  always  be  used  after  delivery  in  cases  of  placenta 
preevia. 

(B.)  Introducing  de  Ribes'  Dilating  Bag. — This  appliance, 
and  the  details  of  the  method  of  using  it,  will  be  found  fully 
described  on  p.  664,  in  the  section  on  Obstetric  Operations. 
Like  the  method  Just  described,  the  dilator  acts  (1)  in 
temporarily  arresting  bleeding  by  compressing  the  placental 
site  ;  (2)  in  exciting  labour  pains.  As  the  uterine  contrac- 
tions become  effective  the  cervix  is  mechanically  dilated  to 
the  size  of  the  broad  end  of  the  bag  (see  Fig.  299).  It  is  un- 
necessary to  alter  the  position  of  the  child,  as  the  method  is 
appKcable  in  all  presentations.  Just  before  introducing  the 
bag  the  membranes  should  be  ruptured  so  that  the  dilator 
will  lie  withm  the  amniotic  cavity.  It  is  therefore  easier  to 
introduce  it  in  cases  in  which  the  edge  of  the  placenta  is 
within  reach.  ^ATien  the  msertion  is  central  the  placental 
tissue  over  the  os  must  be  torn  through  with  the  finger,  and 
the  opening  thus  made  stretched  until  it  is  large  enough  to 
admit  the  bag.  The  introduction  of  the  dilator  under  these 
circumstances  is  undoubtedly  difficult.  When  it  has  been 
introduced  and  inflated  gentle  traction  may  be  exercised, 
jjreferahly  hy  the  hand,  in  order  to  keep  up  continuous  com- 
pression of  the  placental  site. 

As  a  means  of  arresting  haemorrhage  the  bag  is  effective  ; 
but  it  is  inferior  to  pulling  down  a  leg  as  a  means  of  exciting 
labour  pains.  When  traction  is  used,  the  bag  will  often 
dilate  the  cervix  without  inducing  effective  labour  pains  at 
all.  When  the  cervical  canal  has  been  dilated  to  the  full 
size  of  the  bag,  the  latter  passes  out  of  the  uterus  into  the 
vagina.  If  the  uterus  is  now  contracting  well,  so  as  to  drive 
the  presenting  part  well  down  into  the  cervix,  bleeding  will 
not  recur  to  any  serious  extent.  But  if  the  uterus  is  inactive, 
the  removal  of  the  compressing  force  may  lead  to  a  sudden 
profuse  loss  of  blood  when  the  bag  passes  into  the  vagina. 


ANTE-PARTUM   HEMORRHAGE  505 

111  this  respect,  therefore,  the  method  is  decidedly  inferior  to 
pulhng  down  a  leg,  for  in  the  latter  compression  is  necessarily 
maintained  until  the  body  of  the  child  has  been  delivered. 

After  the  bag  has  done  its  work  in  dilating  the  cervix  it  is 
usually  necessary  to  adopt  some  method  of  operative 
delivery,  such  as  forceps  or  internal  version,  and  the  patient 
must  be  most  carefully  watched  in  order  that  there  may  be 
no  delay  in  doing  what  is  required  if  bleeding  recurs  after  the 
expulsion  of  the  bag.  When  the  bag  has  been  expelled  and 
the  uterus  is  inactive,  delivery  must  not  be  delayed  ;  forceps 
extraction  under  anaesthesia  is  the  method  of  choice  in  such 
cases.  Delay  may  be  followed  by  further  profuse  bleeding 
which  greatly  increases  the  risks  of  the  subsequent  extraction 
of  the  child.  In  forceps  operations  the  greatest  care  is 
called  for,  and  delivery  should  be  effected  slowly  ;  as  the 
head  is  pulled  down  into  the  pelvis  the  bleeding  will  cease 
from  efficient  compression  of  the  placental  site. 

Comparison  of  Methods. — For  the  dilating  bag  the  cases 
most  suitable  are  those  of  lateral  and  marginal  placenta 
prsevia,  where  the  membranes  are  within  reach  and  the  bag 
can  be  pushed  through  them.  Cases  of  central  insertion,  on 
the  other  hand,  should  always  be  treated  in  preference  by 
version  for  the  following  reasons  :  {a)  the  child  dies  before 
delivery  in  almost  all  central  cases  owing  to  the  extensive 
separation  of  the  placenta  ;  (&)  the  amount  of  bleeding  is 
always  severe  and  the  condition  demands  such  methods  of 
treatment  as  will  minimise  subsequent  haemorrhage  ;  (c)  ver- 
sion is  the  easiest  method  of  trans-placental  delivery. 
Having  brought  down  the  half-breech  in  a  central  case., 
delivery  should  not  be  at  once  completed  :  the  more  serious 
the  condition  of  the  mother  the  more  necessary  is  it  that 
this  precaution  should  be  observed.  The  time  gained  after 
arrest  of  bleeding  should  be  spent  in  restorative  measures, 
and  delivery  may  then  occur  spontaneously  later  on.  Con- 
tinuous gentle  traction  on  the  breech  may  be  necessary  to 
arrest  bleeding  completely. 

It  may  be  said  that  all  cases  of  placenta  praevia  are 
suitable  for  version.  The  reason  why  it  is  not  in  all  cases 
adopted  is  that  the  foetal  mortality  with  this  method  is 
higher  than  with  the  hydrostatic  bag.  On  the  other  hand 
the  risks  to  the  mother  are  less  with  version.     The  general 


506  ABNORMAL   LABOUR 

rule  which  should  be  observed  is  that  the  bag  may  be  used 
in  the  less  severe  class  of  cases  where  the  amount  of  bleeding 
has  been  comparatively  small.  In  all  cases  where  the  amount 
of  bleeding  has  been  severe,  and  in  central  cases  even  when 
the  bleeding  has  not  at  the  time  been  alarming,  version 
should  be  preferred.  The  conditions  in  the  latter  involve 
maternal  risks  so  serious  as  to  forbid  us  to  allow  them  to  be 
increased  by  adopting  measures  designed  in  the  interests  of 
the  child  alone. 

It  must  further  be  observed  that  when  the  bag  is  used 
the  patient  requires  continuous  medical  supervision,  for  its 
expulsion  may  be  immediately  followed  by  profuse  bleeding. 
With  version,  however,  delivery  may  occur  spontaneously 
without  further  loss  of  blood.  Lender  the  conditions  generally 
found  in  private  practice  the  method  of  version,  for  this 
reason  also,  is  to  be  preferred. 

Treatment  of  Slight  Cases  of  Placenta  Prsevia. — In  slight 
cases  two  methods  are  available,  much  simpler,  and  in- 
volving much  less  interference  than  those  just  described  ; 
they  are  (a)  plugging  the  cervix  and  vagina,  and  (6)  rupturing 
the  membranes.  Plugging  is  carried  out  in  the  manner  to  be 
described  in  connection  with  the  treatment  of  accidental 
haemorrhage  (p.  508).  Large  quantities  of  gauze  are  required 
and  the  upper  part  of  the  vagina  must  be  tightly  packed  if  the 
plug  is  to  be  effective.  This  method  is  mainly  applicable  to 
cases  in  which  labour  has  not  begun  or  the  cervix  is  not 
sufficiently  dilated  to  admit  two  fingers.  Lender  these  con- 
ditions it  will  arrest  bleeding,  and  in  some  cases  also  will 
start  labour  pains.  The  chief  objection  to  it  is  the  difficulty 
of  maintaining  efficient  asepsis.  That  this  is  a  practical 
objection  is  shown  by  the  fact  that  even  in  lying-in  hospitals 
cases  treated  by  plugging  show  a  higher  percentage  of  septic 
complications  than  those  treated  by  any  other  method.  It 
should  therefore  not  be  adopted  except  in  an  emergency. 

Rupture  of  the  Membranes. — This  method  is  very  useful 
when  the  head  or  breech  presents,  the  placenta  is  marginal  or 
lateral,  and  the  amount  of  bleeding  shght  ;  unless  labour  is 
already  in  progress  the  conditions  for  its  performance  are  not 
entirely  favourable,  for  as  a  means  of  inducing  labour  it  is 
unreliable.  Free  escape  of  the  liquor  ammi  permits  the 
presenting  part  to  descend  completely  into  the  lower  uterine 


ANTE-PARTUM   HAEMORRHAGE  507 

segment  and  fill  it  so  as  to  compress  the  placental  site  ;  at 
the  same  time  the  force  and  frequency  of  the  uterine  contrac- 
tions are  increased.  Care  must  be  taken  that  a  loop  of  cord 
does  not  become  prolapsed.  If  the  shoulder  presents  it  is 
contra-indicated.  If  the  breech  presents  it  should  be 
followed  by  pulling  down  a  leg  as  soon  as  sufficient 
dilatation  has  been  accomplished.  Whenever  it  is  clear 
that  the  child  is  dead  delivery  may  be  rendered  easier  by 
reducing  the  size  of  the  head  by  craniotomy. 

Csesarean  Section  in  the  Treatment  of  Placenta  Praevia. — 
A  certain  amount  of  experience  has  been  gained  during  the 
last  few  years  of  the  performance  of  Csesarean  section  in 
cases  of  placenta  praevia.  This  operation  has  been  done 
chiefly  in  cases  of  central  insertion,  for  in  these  the  mechanical 
difficulties  of  delivery  jper  vias  naturales  are  the  greatest,  and 
the  degree  of  haemorrhage  is  always  severe.  It  may  be 
considered  in  all  cases  in  which  there  has  been  serious 
haemorrhage,  and  in  which  from  the  position  of  the  placenta 
it  is  anticipated  that  delivery  cannot  be  effected  without 
further  serious  loss  of  blood.  In  such  cases  Caesarean 
section,  performed  after  the  first  attack  of  bleeding  has 
occurred,  offers  almost  the  only  chance  of  the  survival  of  the 
child,  and  is  probably  less  dangerous  to  the  mother  than 
delivery  by  the  natural  channels.  At  the  same  time  it  must 
be  remembered  that  delivery  by  Caesarean  section  cannot  be 
ejected  without  the  loss  of  a  considerable  amount  (one 
half  pint)  of  blood.  In  addition,  the  amount  of  shock 
attending  an  abdominal  operation  is  certainly  greater  than 
that  attending  delivery  after  pulling  down  a  leg.  Caesarean 
section  is  not  here  contra-indicated  by  death  of  the  child, 
for  the  operation  is  mainly  undertaken  in  the  maternal 
interests.  In  order  to  reduce  operative  shock  the  operation 
should  be  performed  by  the  so-called  "  shockless  "  method, 
i.e.,  by  the  use  of  local  anaesthesia  supplemented  by  a 
minimum  amount  of  an  innocuous  general  anaesthetic  such 
as  gas  and  oxygen.  Intravenous  saline  transfusion  will 
usually  be  required  either  before  or  during  the  operation. 

Treatment  of  Accidental  Haemorrhage. — 1.  When  the 
hcemorrhage  is  external. — In  the  early  stages  of  labour,  the 
cervix  being  closed  or  only  large  enough  to  admit  two  fingers, 
two  methods  of  treatment  are  apjDlicable— viz.,  vaginal  plug- 


508  ABNORMAL   LABOUR 

ging  and  rupture  of  the  membranes.  The  former  is  the 
method  introduced  and  advocated  at  the  Rotunda  Hospital, 
Dubhn,  and  now  generally  accepted  and  practised.  The 
object  in  view  is  twofold — firstly,  to  stimulate  the  uterus  and 
so  induce  effective  labour  pains  ;  secondly,  to  prevent 
further  haemorrhage.  The  vaginal  plug  does  not  directly 
control  bleeding,  as  in  the  case  of  placenta  prsevia  ;  but  it  is 
claimed  for  it  that,  by  preventing  the  escape  of  the  effused 
blood,  when  the  uterus  is  actively  contracting,  the  intra- 
uterine pressure  will  be  raised  to  a  point  at  which  it  equals  or 
exceeds  the  blood-pressure  in  the  placental  sinuses,  and 
accordingly  the  bleeding  will  cease  spontaneously.  It  is 
clear  that  this  eJffect  will  not  be  produced  unless  the  plug 
excites  effective  uterine  contractions.  The  plugging  is 
carried  out  as  follows :  The  vulva  should  be  shaved  and,  after 
thorough  antiseptic  douching  and  swabbing,  the  vaginal 
canal  is  tightly  plugged  from  the  fornices  to  the  vulva  with 
strips  of  antiseptic  gauze  ;  an  abdominal  binder  tight 
enough  to  compress  the  uterus  is  next  appHed  ;  finally  a 
large  pad  of  wool  is  placed  over  the  vulva,  and  a  bandage 
carried  tightly  from  the  binder  behind,  over  the  vulval  pad, 
and  fixed  to  the  binder  in  front.  Full  doses  of  ergot  are  also 
given  by  the  mouth  or  by  subcutaneous  injection.  Un- 
ruptured membranes  are  of  great  assistance  in  maintaining 
intra-uterine  tension.  If  uterine  contractions  are  not  power- 
fullv  excited,  this  treatment  may  convert  the  case  into  one 
of  concealed  haemorrhage  by  preventing  the  escape  of  effused 
blood.  This  untoward  result  does  undoubtedly  occur,  but 
experience  shows  that  j)lugging  by  this  method  rarely  fai^s 
to  excite  effective  contractions. 

It  has  been  already  mentioned  that  vaginal  plugging  is 
difficult  to  carry  out  under  complete  asepsis,  and  that  septic 
complications  are  frequent  after  its  use.  The  risk  of  sepsis  is 
probably  less  in  accidental  haemorrhage  than  in  placenta 
praevia  on  account  of  the  low  position  of  the  placenta  in 
the  latter.  The  efficiency  of  the  method  in  suitable  cases 
and  the  simpficity  of  its  requirements  render  it  of  real  value 
in  accidental  haemorrhage. 

Rupture  of  the  membranes  is  the  other  alternative  at 
this  stage  ;  its  object  is  to  excite  effective  contractions 
and   thus  accelerate  labour.     This  effect  is,  however,  less 


ANTE-PARTUM   HEMORRHAGE  509 

certainly  produced  than  by  vaginal  plugging.  It  should 
only  be  used  at  this  stage  if  the  bleeding  is  slight  or  has 
ceased,  and  the  amount  of  blood  which  has  been  lost  is 
inconsiderable.  Before  rupturing  the  membranes  a  head 
presentation  should  be  produced  by  external  version  if  any 
other  part  presents.  Afterwards,  a  tight  abdominal  binder 
should  be  applied,  and  full  doses  of  ergot  given  until 
effective  pains  have  been  excited. 

The  matter  may  therefore  be  summed  up  by  saying  that 
in  the  early  stages  severe  cases  of  external  accidental 
haemorrhage  should  be  treated  by  plugging,  slight  cases  by 
rupturing  the  membranes. 

In  the  further  management  of  labour  it  must  be  recollected 
that  in  many  cases  accidental  haemorrhage  ceases  spon- 
taneously, and  after  a  severe  loss  at  the  beginning  of  labour 
no  more  bleeding  may  occur.  Or  if  the  bleeding  recurs  it  is 
not  necessarily  in  large  quantity.  In  this  respect  the 
conditions  are  very  different  from  placenta  praevia,  in  which 
haemorrhage  continues  throughout  the  stage  of  dilatation 
unless  checked  by  treatment.  When  the  bleeding  has  ceased 
or  is  inconsiderable  and  the  cervix  is  sufficiently  dilated^ 
de  Ribes'  bag  may  be  used  for  dilating  the  cervix  so  that 
delivery  may  be  rapidly  completed  by  forceps  or  version. 

2.  When  the  hcemorrhage  is  concealed. — In  severe  cases  of 
concealed  haemorrhage  there  is  complete  uterine  inertia,  and 
it  is  almost  impossible  to  induce  effective  labour  pains  owing 
to  paralysis  of  the  uterine  muscle  from  over-distension.  Two 
lines  of  treatment  have  to  be  considered,  and  the  choice  is 
often  difficult,  requiring  great  care  and  judgment.  (1)  The 
vagina  may  be  plugged  and  a  binder  applied  in  the  hope  of 
exciting  pains,  and  the  attention  then  devoted  to  restoring 
the  patient's  strength  by  administration  of  stimulants,  saline 
enemata,  or  saline  transfusion.  In  the  absence  of  skilled 
assistance,  and  in  surroundings  unsuitable  for  serious 
operative  measures,  this  is  probably  the  best  treatment  to 
pursue.  (2)  In  hospital  practice,  and  when  the  patient's 
surroundings  are  suitable  for  a  major  operation,  the  case 
may  be  treated  by  Caesarean  section  or  by  the  removal  of 
the  entire  unopened  uterus.  Since  the  uterus  in  concealed 
haemorrhage  is  nearly  always  an  organ  exhausted  by  repeated 
child-bearing,  it  may  be  urged  that  it  should  be  removed  in 


510  ABNORMAL   LABOUR 

the  mother's  interests.  If  removed  unopened,  there  is 
probably  less  fresh  loss  of  blood  than  if  removed  by  the 
usual  procedure  in  Csesarean  hysterectomy  (p.  735). 
Where  such  an  operation  is  performed  the  precautions 
described  in  connection  with  Csesarean  section  for  placenta 
prsevia  must  be  strictly  observed.  As  may  be  expected,  a 
high  maternal  mortality  attends  this  very  serious  condition, 
by  whatever  method  it  may  be  treated. 

Mortality. — Out  of  10,000  recent  consecutive  admissions, 
119  cases  of  placenta  prsevia  were  treated  at  Queen  Char- 
lotte's Hospital.  The  maternal  mortahty  in  these  cases 
was  10  per  cent.,  but  it  must  be  remembered  that  many 
of  these  cases  were  admitted  during  labour,  after  severe 
bleeding  had  occurred  and  various  methods  of  treatment 
had  been  applied.  The  foetal  mortahty  in  the  same 
series,  calculated  upon  the  number  which  died  either  during 
delivery  or  before  leaving  the  Hospital,  was  67  per  cent. 
During  the  same  period  129  cases  of  accidental  haemorrhage 
occurred  with  a  maternal  mortahty  of  4  per  cent,  and  an 
infantile  mortahty  of  58  per  cent.  These  figures  iUustrate 
very  well  the  greater  seriousness  of  placenta  prsevia  from 
the  point  of  view  of  the  maternal  risks,  and  also  the  heavy 
foetal  mortahty  which  attends  both  varieties  of  ante- 
partum haemorrhage.  The  foetal  mortahty  is  in  part 
accounted  for  in  both  cases  by  prematurity.  In  the  majority 
of  the  fatal  cases  of  placenta  prsevia  the  insertion  was  central. 
Accidental  hsemorrhage  is  seen  to  be  both  more  frequent  and 
on  the  average  less  serious  than  placenta  prsevia.  In 
addition  to  the  maternal  mortality  there  is  a  relatively  high 
rate  of  puerperal  morbidity  from  septic  comphcations. 

Non-expulsion  of  the  Placenta 

The  natural  expulsion  of  the  placenta  may  be  prevented 
{a)  by  uterine  inertia,  (6)  by  morbid  adhesion  of  the  placenta 
or  membranes  to  the  uterine  wall,  (c)  by  the  formation  of  a 
contraction  ring  ;  in  all  these  conditions  severe  hsemorrhage 
may  occur  unless  the  placental  attachments  remain  un- 
disturbed. If  the  placenta  retains  its  complete  attachments 
undisturbed  there  wiU  be  little  hsemorrhage,  for  none  of  the 
utero-placental  vessels  have  been  torn  ;    when,  however, 


RETAINED   PLACENTA  511 

it  is  in  part  but  not  wholly  detached,  and  the  uterus  is 
unable  to  expel  it  into  the  cervix,  uterine  retraction  is 
impeded  and  free  bleeding  occurs  from  the  imperfectly  closed 
mouths  of  those  vessels  which  have  been  torn.  Though 
the  normal  processes  of  separation  and  expulsion  of  the 
placenta  and  membranes  are  always  accompanied  by 
haemorrhage,  the  amount  does  not  usually  exceed  4  to  6 
ounces,  and  is  not  enough  to  quicken  the  pulse-rate  or  affect 
the  general  condition  of  the  mother.  Unusually  free 
bleeding  at  this  period  (third  stage)  is  always  due  either  to 
incomplete  detachment  of  the  placenta  or  to  laceration  of  some 
part  of  the  genital  canal — the  cervix,  vagina,  or  vulva. 
The  latter  will  be  considered  in  the  next  section  in  connection 
with  post-partum  hsemorrhage. 

(1)  Retention  of  the  Placenta.  Uterine  Inertia. — In  this 
condition  spontaneous  delivery  of  the  placenta  does  not 
occur,  and  the  after-birth  remains  in  organic  union  with  the 
wall  of  the  uterus,  although  its  attachments  are  not  abnor- 
mal. The  cause  of  the  non-detachment  of  the  placenta  must 
be  inadequacy  of  uterine  retraction  and  contraction,  for  no 
abnormality  can  be  detected  in  the  placental  attachments. 
Sometimes  no  haemorrhage  occurs  ;  more  frequently  a 
portion  of  the  placenta  becomes  separated,  and  then  there  is 
haemorrhage,  which  may  be  very  profuse,  some  of  the  most 
serious  cases  of  post-partum  haemorrhage  being  met  with 
before  the  placenta  has  been  delivered.  A  practitioner  in  a 
hurry  may  be  tempted  to  diagnose  retention  whenever  the 
placenta  is  not  expelled  within  a  few  minutes  after  the 
delivery  of  the  child  ;  this  is  unjustifiable,  and  at  least  an 
hour  should  be  allowed  to  elapse,  unless  there  is  unusual 
haemorrhage,  before  the  case  is  regarded  as  abnormal. 
When  there  is  no  haemorrhage  the  condition  is  not  urgent, 
and  delay  can  do  no  harm  ;  if  there  is  much  haemorrhage  no 
delay  can,  of  course,  be  allowed.  If  the  placenta  cannot  be 
expressed  (see  p.  335)  the  treatment  consists  in  digital 
removal  of  the  after-birth  from  the  uterus.  In  the  case  under 
consideration,  no  difficulty  whatever  attends  the  detachment 
of  the  placenta  by  the  fingers,  showing  that  there  is  no 
structural  abnormality.  But  this  operation,  though  simple 
and  easy,  is  attended  by  definite  risks,  and  should  never  be 
undertaken  merely  to  save  time. 


512  ABNORMAL  LABOUR 

(2)  Morbid  Adhesion  of  the  Placenta. — The  pathology  of 
this  condition  is  imperfectly  understood.  Clinically  it  is 
characterised  by  unusual  firmness  of  the  placental  attach- 
ments, in  consequence  of  which  spontaneous  delivery  is 
rendered  impossible.  It  is  rare  for  the  whole  placental  site 
to  be  thus  affected  ;  usually  the  change  is  partial  in  extent. 
It  is  attributed,  and  with  probability,  to  inflammatory 
changes  in  the  decidua,  resulting  in  the  formation  of  more 
or  less  extensive  firm  organic  connections  with  the  uterine 
wall.  From  this  view  it  is  easy  to  proceed  to  the  assump- 
tion that  some  form  of  decidual  endometritis  is  the  original 
lesion  ;  and  this  assumption  is  supported  by  the  observation 
that  the  condition  not  infrequently  recurs  in  successive 
pregnancies.  But  pathological  proof  has  not  yet  been 
advanced,  because  it  is  difhcult  to  obtain  material  in  a  suit- 
able condition  for  histological  examination,  inasmuch  as  the 
placenta,  in  these  cases,  is  usually  obtained  in  fragments  torn 
from  the  uterine  wall. 

Morbid  adhesion  of  the  placenta  usually  causes  severe 
haemorrhage  in  the  third  stage,  but  sometimes  there  is  little 
or  none.  The  amount  of  bleeding  depends  mainly  upon  the 
extent  of  the  adherent  area  ;  when  this  is  large,  only  a  small 
part  of  the  placental  site  can  be  laid  bare — i.e.  can  give  rise  to 
haemorrhage  ;  when  the  adherent  area  is  small  a  large  extent 
of  the  placental  site  may  be  denuded  and  thus  cause  severe 
bleeding. 

Simple  retention  and  morbid  adhesion  of  the  placenta  can 
only  be  distinguished  from  one  another  by  digital  separation 
of  the  after-birth.  In  the  former  condition  this  is  easy  ; 
in  the  latter  it  is  difficult  owing  to  the  presence  of  dense 
fibrous  bands  which  must  be  torn  through,  or  owing  to  firm 
union  between  the  placental  and  uterine  surfaces.  The 
treatment  of  a  morbidly  adherent  placenta  is  the  same  as 
of  a  retained  placenta — viz.  to  remove  it  by  intra-uterine 
manipulation. 

(3)  Morbid  Adhesion  of  the  Membranes. — When  this 
occurs,  the  placenta,  though  expelled  from  the  uterine  cavity, 
remains  suspended  in  the  cervix  or  vagina  by  non-separation 
of  the  chorion  from  the  uterine  wall  (Fig.  121),  and  cannot  be 
delivered  by  voluntary  expulsive  efforts  or  by  gentle  com- 
pression.    Abdominal  examination  shows  that  the  placenta 


RETAINED   PLACENTA  513 

has  left  the  uterus.  If  energetic  compression  of  the  uterus  is 
practised  the  placenta  may  be  torn  away  and  expelled  with 
the  amnion,  leaving  a  large  part  of  the  chorion  in  the  uterus. 
In  point  of  fact  this  is  what  usually  occurs  in  such  cases,  and 
the  fact  that  the  membranes  are  morbidly  adherent  is  not 
recognised  until  the  after-birth  has  been  delivered,  when  it 
is  found  on  examination  that  the  chorion  is  deficient.  The 
amnion  is  seldom  adherent  and  usually  comes  away  entire 
with  the  placenta.  If  the  condition  is  recognised  before  the 
delivery  of  the  placenta,  no  further  attempts  to  deliver  it 
by  compression  should  be  made,  but  digital  detachment 
should  be  practised,  the  fingers  being  passed  up  the  side  of 
the  placenta  into  the  uterus  to  the  site  of  the  adhesion. 
When  it  is  found  that  a  piece  of  the  chorion  has  been  torn  off, 
a  vaginal  examination  should  be  made,  and  if  the  piece  is 
found  hanging  down  into  the  vagina  it  should  be  carefully 
removed  by  twisting  it  with  a  pair  of  forceps.  If  the  end 
cannot  be  felt  in  the  vagina,  nothing  further  should  be  done  ; 
the  piece  of  membrane  will  become  detached  and  sponta- 
neously expelled  during  the  first  week  of  the  puerperium, 
and  if  efficient  asepsis  has  been  secured,  no  harm  results. 
The  alternative  is  to  explore  the  uterus  by  passing  the 
whole  hand  into  it,  and  this  procedure,  even  when  carefully 
carried  out,  often  results  in  bacteria  being  carried  from  the 
vulva  into  the  uterus.  A  high  percentage  of  morbidity 
from  sepsis  is  found  in  cases  in  which  the  hand  has  been 
passed  into  the  uterus  during  or  after  the  third  stage  of 
labour. 

(4)  Co7itraction  Ring  (Hour-glass  Contraction). — The 
causation  of  this  condition  has  been  already  discussed 
(p.  450)  in  connection  with  its  occurrence  in  earlier  stages  of 
labour.  In  the  third  stage  it  causes  great  narrowing  of 
the  lumen  of  the  uterus  and  prevents  the  expulsion  of  the 
placenta.  The  upper  part  of  the  uterine  body,  which, 
though  retracted,  is  lax  and  contains  the  placenta,  is  sepa- 
rated by  a  ring  of  spasm  from  the  lower  segment  and  cervix, 
which  are  also  lax  ;  hence  the  name  of  hour-glass  contraction 
which  has  been  applied  to  it  (Fig.  257).  The  condition 
occurs  after  prolonged  or  difficult  labour,  but  the  adminis- 
tration of  ergot  before  delivery,  at  one  time  regarded  as  the 
principal  cause,  has  probably  little  to  do  with  its  causation. 
E.M.  33 


514 


ABNORMAL  LABOUR 


A  similar  condition  may  occur  in  the  first  and  second  stage 
of  labour,  and  has  been  already  referred  to. 

If  the  placenta  becomes  partly  or  wholly  separated  there 
will  be  severe  haemorrhage,  for  its  expulsion  through  the 
ring  of  spasm  is  impossible  ;  if  not,  there  will  be  none.  In 
the  former  case  immediate  removal  of  the  placenta  is  called 


Fig.  257. — Retention  of  th.e  Placenta  due  to  a  Contraction  Eing. 
(After  Bumm.) 

for  ;  in  the  latter,  it  is  best  to  wait  for  two  or  three  hours 
before  attempting  removal,  in  order  to  get  rid  of  the  local 
spasm  ;  this  may  be  aided  by  the  administration  of  a  fuU 
dose  of  morphia  hypodermicaUy  (^  grain).  Considerable 
difficulty  may  be  experienced  in  dilating  the  ring  of  spasm,  if 
the  operation  has  to  be  undertaken  immediately. 

Sometimes  the  presence  of  a  fibroid  tumour  in  the  lower 


RETAINED   PLACENTA  515 

part  of  the  uterine  wall  will  offer  the  same  kind  of  obstacle 
to  spontaneous  expulsion,  and  the  same  kind  of  difficulty  in 
artificial  delivery,  as  irregular  retraction. 

Digital  Removal  of  the  Placenta. — This  operation  should 
not  be  lightly  undertaken,  for  it  is  by  no  means  devoid  of 


Fig.  258.— Introducing  the  Hand  into  the  Vagina. 

risk.  An  anaesthetic  should  be  given,  and  the  patient  placed 
in  the  dorsal  position  with  the  legs  supported  by  attendants 
or  a  Clover's  crutch.  The  most  scrupulous  antiseptic  pre- 
cautions must  be  taken  in  sterilising  the  hands  and  vulva 
and  a  pair  of  previously  sterilised  rubber  gloves  should 
be  used  in  all  cases.  A  hot  (118°  F.)  intra-uterine  douche 
shoTild  be  prepared  for  administration  at  the  close  of  the 

33—2 


516 


ABNORMAL  LABOUR 


operation.  Either  hand  may  be  passed  into  the  vagina, 
the  other  being  employed  to  steady  the  uterus.  The  fingers 
and  thumb  should  be  bent  into  the  shape  of  a  cone 
(Fig.  258),  and  the  whole  hand  gently  introduced  through 


Fig.  259. — Digital  Separation  of  the  Placenta. 

the  vulva,  the  labia  bemg  separated  with  the  fingers  of  the 
other  hand  ;  the  whole  hand  may  then  be  passed  up  between 
the  membranes  and  the  uterine  wall  until  the  lower  placental 
border  is  reached.  If  the  fingers  are  inadvertently  passed 
inside  the  collapsed  amniotic  sac,  they  must  be  withdrawn 
and  re-introduced  outside  the  membranes. 


RETAINED   PLACENTA  517 

In  a  case  of  simple  retention  it  wiU  be  found  to  be  perfectly 
easy  to  insinuate  the  fingers  under  the  placental  edge,  and 
gradually  detach  it  from  the  uterus,  the  fingers  sweeping  the 
wall  on  both  sides  (Fig.  259).  This  should  be  continued  until 
the  whole  of  the  placenta  has  been  completely  detached  ; 
then  the  mass  is  grasped  in  the  fingers  and  gently  withdrawn 
into  the  vagina,  the  membranes  being  peeled  off  behind  it. 
The  fundus  is  steadied  by  the  other  hand  grasping  it 
until  the  operation  is  finished.  It  is  important  fully  to 
detach  the  placenta  before  beginning  to  remove  it,  otherwise 
fragments  may  easily  be  torn  off  and  left  behind.  Every 
effort  should,  however,  be  made  to  detach  the  whole  of  the 
placenta  and  sweep  it  out  of  the  uterus  before  withdrawing 
the  hand,  thus  avoiding  the  necessity  of  introducing  it  a 
second  time.  Immediately  after  the  placenta  has  been 
removed  it  should  be  examined,  and  if  it  or  the  membranes 
are  incomplete  the  hand  must  again  be  introduced  and  the 
retained  portions  removed,  A  hot  intra-uterine  douche 
should  then  be  administered  to  stimulate  retraction  and 
remove  clots,  and  to  counteract  the  possible  effects  of  the 
introduction  of  air  or  impurities.  A  dose  of  ergot  should  be 
given,  and  it  is  important  to  make  sure  that  the  uterine 
cavity  is  completely  empty,  as  described  on  p.  336.  Care- 
lessness in  performing  this  operation  may  result  in  perfora- 
tion of  the  uterus,  incomplete  removal  of  the  placenta,  or 
troublesome  haemorrhage  ;  in  spite  of  precautions  a  mild 
uterine  infection  frequently  occurs  in  the  puerperium. 

When  there  is  morbid  adhesion  of  the  placenta,  difficulties 
will  be  encountered.  In  this  case  it  is  best  to  begin  with  the 
detached  portion,  if  this  can  be  foim,d.  The  finger-tips  must 
be  used  in  clearing  the  uterine  wall,  and  great  gentleness  is, 
of  course,  called  for  in  all  the  manipulations.  The  use  of  the 
curette  is  inadmissible,  but  blunt  ovum  forceps  (Fig.  235) 
may  be  used  to  seize  and  detach  portions  of  placenta  which 
cannot  be  separated  by  the  fingers.  Every  effort  should  be 
made  to  remove  completely  the  whole  of  the  placenta  and 
chorion,  but  it  is  often  difficult  to  make  certain  that  this  has 
been  done. 

In  irregular  retraction  the  difficulty  consists  in  dilating 
the  ring  of  spasm  sufficiently  to  admit  the  fingers  and  allow 
of  the  removal  of  the  placenta.     A  full  hypodermic  dose  of 


518    .  ABNORMAL   LABOUR 

morphia  given  beforehand  assists  the  anaesthetic  in.  relaxing 
the  spasm.  Dilatation  should  be  performed  with  the  fingers 
alone. 

Post-partutn  Haemorrhage 

Haemorrhage  which  occurs  after  delivery  is  called  post- 
partum haemorrhage  ;  its  occurrence  is  most  to  be  feared 
immediately,  or  within  an  hour  or  two  after  labour  is  over. 
Haemorrhage  occurring  after  the  first  day  of  the  puerperium 
is  called  secondary  post-partum  hcemorrhage,  or  puerperal 
hcemorrhage  ;  the  latter  term  is  preferable,  as  it  is  desirable 
not  to  confuse  it  with  the  form  of  haemorrhage  under  con- 
sideration. Many  fives  have  been  lost  from  this  compfica- 
tion  of  labour  ;  bleeding  may  supervene  so  suddenly  and 
profusely  that,  unless  it  can  be  checked,  death  will  ensue 
within  half  an  hour  to  an  hour.  A  disaster  such  as  this  may 
follow  a  rapid  and  apparently  an  easy  labour  ;  it  is  therefore 
of  the  first  importance  that  its  causation,  and  the  principles 
which  underHe  its  prophylaxis  and  immediate  treatment, 
should  be  clearly  understood.  In  proportion  as  these  prin- 
ciples are  generally  acted  upon,  pos't-partum  haemorrhage 
becomes  less  frequent  and  less  formidable. 

Causation. — There  are  only  three  local  conditions  which 
can  be  regarded  as  immediate  causes  of  post-partum  haemor- 
rhage— ^viz.  uterine  exhaustion  or  inertia,  mechanical  obstacles 
to  retraction,  and  lacerations  of  some  part  of  the  genital  tract 
(cervix,  vagiria,  vulva)  ;  in  the  two  former  the  bleeding 
comes  from  the  torn  utero-placental  vessels  (placental  site)  ; 
in  the  latter  from  torn  vessels  at  the  seat  of  injury.  Uterine 
exhaustion  at  this  period  impHes  failure,  more  or  less  com- 
plete, of  both  contraction  and  retraction — i.e.  it  is  identical 
with  the  condition  previously  described  as  secondary  iuertia 
(p.  443).  Cases  of  real  gravity  which  imperil  or  destroy  life 
are  generally  due  to  this  cause  ;  it  is  obvious  that  exhaustion 
of  the  uterus,  when  the  placenta  has  been  separated,  will 
allow  of  haemorrhage  of  the  most  profuse  kind,  for  muscular 
action  is  the  only  effectual  means  of  closing  the  mouths  of 
the  torn  utero-placental  sinuses.  The  circumstances  which 
may  lead  directly  or  indirectly  to  post-partum  uterine  inertia 
must  therefore  be  carefully  borne  in  mind  ;   they  can   be 


POST-PARTUM   HAEMORRHAGE  519 

conveniently  grouped  into  predisposing  and  immediate  causes. 
As  they  have  all  been  previously  considered  in  detail,  little 
more  than  an  enumeration  of  them  is  here  required. 

Predisposing  Causes  of  Post-partum  Inertia. — Multiparity, 
especially  when  associated  with  rapid  child-bearing,  is  the 
most  important  ;  such  cases,  in  other  words,  as  are  liable  to 
secondary  inertia  during  labour.  Post-partum  haemorrhage 
from  inertia  in  a  primipara  is  rare.  Debility,  especially  as 
met  with  among  the  poor  from  insufficient  feeding  and 
insanitary  occupations  or  surroundings,  is  also  of  importance. 
Over-distension  of  the  uterus  (twins,  hydramnios),  ante- 
partum hcemorrhage,  secondary  inertia  during  the  second 
stage,  protracted  or  precipitate  labour,  and  prolonged  anaesthesia 
must  all  be  regarded  as  conditions  which  increase  the  risks 
of  the  occurrence  of  post-partum  inertia. 

Immediate  Causes  of  Post-partum  Inertia. — Artificial 
delivery  of  the  child  during  a  period  of  secondary  inertia 
involves  serious  risk  of  post-partum  haemorrhage,  as  has 
been  already  explained  in  another  place.  It  may  be  repeated 
here  that  absolute  cessation  of  the  pains  of  labour  forms 
a  contra-indication  to  delivery.  One  of  the  causes  most 
frequently  met  with  is  mismanagement  of  the  third  stage  of 
labour.  The  importance  of  continuous  manipulation  of  the 
uterus  during  and  after  this  stage  has  been  pointed  out ;  if 
this  precaution  is  neglected  the  uterus  may  fill  with  blood 
and  even  become  distended  (relaxed)  without  any  external 
bleeding  attracting  attention  ;  serious  loss  of  blood  may 
then  occur,  which  will  in  turn  induce  an  extreme  degree 
of  inertia.  The  uterus  very  generally  requires  stimulation 
at  this  period  of  labour.  Sometimes  post-partum  inertia 
appears  to  be  reflexly  induced  by  a  full  bladder,  and  it  may 
also  without  doubt  be  brought  on  by  nervous  shock.  It  is 
probable  also  that  in  some  cases  inertia  is  complicated  by 
deficient  coagulability  of  the  blood  preventing  the  formation 
of  thrombi  in  the  mouths  of  the  sinuses,  but  with  the  excep- 
tion of  some  varieties  of  anaemia  and  the  rare  disease  haemo- 
philia, we  know  nothing  of  the  conditions  which  cause  it. 
Since  efficient  retraction  of  the  uterine  muscle  suffices  of 
itself  for  the  immediate  arrest  of  the  haemorrhage,  deficient 
coagulability  of  the  blood  is  of  secondary  importance. 

Incomplete  Retraction. — ^Mechanical  obstacles  to  proper 


520  ABNORMAL  LABOUR 

retraction  will  occur  when  portions  or  the  whole  of  the 
placenta  or  membranes  have  been  retained  in  the  uterus,  and 
sometimes  when  there  is  a  fibroid  tumour  in  its  wall.  It  does 
not  necessarily  imply  want  of  activity  of  the  uterine  muscle. 

Lacerations. — Those  which  affect  the  cervix  and  run  up 
into  the  vaginal  roof,  so  as  to  open  the  broad  hgament  to  a 
greater  or  less  extent,  are  the  most  formidable  ;  arteries  of 
considerable  size,  and  large  venous  plexuses,  may  be  laid 
open,  giving  rise  to  free  bleeding.  Tears  of  the  vulva  and 
lower  vaginal  walls  seldom  cause  severe  haemorrhage  ;  but 
it  must  be  remembered  that  the  large  artery  to  the  clitoris 
may  be  lacerated  by  a  tear  of  the  anterior  part  of  the  vulva, 
or  the  artery  to  the  bulb  by  a  deep  lateral  tear  of  the  periaeal 
body. 

Diagnosis. — Post-partum  haemorrhage  is  usually  external ; 
it  may,  however,  be  either  partly  or  entirely  concealed  from 
distension  of  the  uterus  with  blood-clot,  or  from  the  forma- 
tion of  a  large  broad-ligament  hsematoma.  The  condition  of 
the  uterus  is  an  important  indication  of  the  cause  of  the 
bleeding  ;  for  if  exhausted  it  is  soft  and  flabby,  with  in- 
distinct outlines  ;  but  if  the  bleeding  comes  from  a  laceration 
the  uterus  will  probably  be  found  to  be  hard  and  well 
retracted.  Uterine  inertia  and  lacerations  may,  of  course, 
exist  in  company  ;  it  is  necessary  to  remember  this  when 
haemorrhage  continues  after  proper  retraction  of  the  uterus 
has  been  secured.  Careful  digital  examination  will  be 
required  to  detect  deep  lacerations  involving  the  vaginal 
roof. 

A.  Treatment  of  Haemorrhage  from  Inertia. — In  normal 
labour  the  separation  and  expulsion  of  the  placenta  are 
neither  accompanied  nor  followed  by  serious  bleeding 
because  the  mouths  of  the  torn  maternal  vessels  are  imme- 
diately closed  by  continuous  retraction  of  the  uterine  muscle, 
especially  of  the  reticulated  layer  ;  after  the  lapse  of  a  few 
hours  firm  thrombi  are  formed  in  the  mouths  of  the  torn 
vessels,  which  plug  them  securely.  Retraction  is  at  first 
by  far  the  more  important  ;  for  thrombosis  alone  must  be 
powerless  to  prevent  haemorrhage  from  large  arteries  until 
time  has  been  allowed  for  the  consohdation  of  the  thrombi. 
The  treatment  of  post-partum  haemorrhage  from  inertia 
must  therefore  be  directed  in  the  main  towards  restoring  the 


POST-PARTUM  HAEMORRHAGE 


521 


suspended  activity  of  the  uterine  muscle,  efforts  to  promote 
thrombosis  being  relegated  to  a  strictly  secondary  position. 
When  stimulation  of  the  uterus  is  unsuccessful,  bleeding  can 
be  temporarily  arrested  by  compression  of  the  organ,  while 
time  is  allowed  for  the  recovery  of  the  functions  of  the  muscle. 
In  severe  cases  there  is  no  time  to  lose,  and  it  is  of  the  utmost 


y 


Pig.  260. — Expression  of  the  Placenta  by  Pushing  the  Contracting 
Uterus  Downwards  and  Backwards  into  the  Pelvis. 


importance  that  the  treatment  adopted  should  be  prompt 
and  efficient.  The  following  methods  of  stimulating  the 
uterus  should  be  employed  consecutively,  and  in  the  order 
stated,  until  success  is  attained  : 

I  (1)  Manipulation  of  the  Uterus  per  Abdomen. — At  the 
first  sign  of  unusual  haemorrhage  this  method  can  be  instantly 
applied  ;  it  is  therefore  mentioned  first.     The  uterus  should 


522  ABXOmiAL   LABOUR 

be  seized  with  both  hands,  rubbed  and  squeezed,  firmly  and 
continuously,  until  it  is  felt  to  respond  by  becoming  harder 
as  it  is  manipulated.  If  the  placenta  has  not  been  delivered 
it  should  at  once  be  expressed,  or  if  necessary  removed  by 
introducing  the  carefully  sterihsed  and  gloved  hand  into  the 
uterus.  When  fairly  contracted  the  uterus  should  be  firmly 
squeezed  in  the  hand,  and  pressed  downwards  and  backwards 
in  order  to  express  all  blood-clot  from  it  (Fig.  260).  Firm 
retraction  will  not  be  obtained  until  the  uterine  cavity  has 
been  completely  emptied.  Even  when  the  bleeding  has 
apparently  been  controlled  in  this  manner,  gentle  massage 
must  be  kept  up  for  half  an  hour  or  more,  as  relaxation  may 
recur.  Difficulty  in  appljdng  this  method  may  be  met  with 
when  the  hsemorrhage  is  concealed  and  the  uterus  distended 
and  flabby.  Such  cases  are  better  dealt  with  in  the  first 
instance  by  clearing  out  the  uterus. 

(2)  Administration  of  Ergot. — A  full  dose  of  ergot  may 
be  given  as  soon  as  abdominal  compression  is  begun.  Its 
effect  is  produced  most  rapidly  when  given  by  deep  intra- 
muscular injection,  and  the  buttock  is  a  convenient  spot  for 
the  purpose.  1  c.c.  of  a  20  per  cent,  solution  of  pituitary 
extract  or  ten  to  twenty  minims  of  the  injectio  ergotinae 
hypodermica  may  be  given  ;  these  solutions  should  always 
be  sterilised.  If  given  by  the  mouth,  the  dose  should  be 
from  one  to  two  drachms  of  the  extractum  ergotse  Hquidum. 
While  very  useful  in  cases  of  moderate  severity,  ergot  appears 
to  have  no  effect  upon  a  completely  exhausted  uterus,  and  if 
the  condition  of  the  patient  is  very  serious,  time  should  not 
at  this  stage  be  occupied  in  administering  it. 

(3)  Hot  Douches. — While  abdommal  compression  is  being 
practised  the  nurse  in  attendance  can  prepare  a  hot  douche 
(temperature  120°  F.)  of  boiled  water,  or  some  mild  anti- 
septic such  as  lysol  (a  teaspoonful  to  a  quart).  This  is  a 
valuable  supplement  to  abdominal  manipulation,  for  it 
powerfully  stimulates  the  retraction  of  the  uterine  muscle. 
Given  through  a  long  tube  passed  up  to  the  fundus  of  the 
uterus,  it  is  of  course  more  effectual  than  when  employed 
vaginally.  The  medical  attendant  cannot  leave  the  uterus 
Avhen  there  is  serious  bleedmg  in  order  to  prepare  the  douche, 
and  unless  a  rehable  nurse  is  present,  it  had  better  be 
omitted   at   this   stage.     It   is    of   the   greatest  service   in 


POST-PARTUM  HAEMORRHAGE  523 

increasing  and  maintaining  retraction  when  the  haemorrhage 
has  been  to  a  great  extent  controlled  by  other  means,  but  it 
is  of  little  use  to  give  it  until  the  uterus  has  been  fairly  well 
emptied  of  blood-clot  by  compression  or  by  the  method  next 
to  be  described. 

(4)  Clearing  outjhe  Uterus. — When  abdominal  compres- 
sion fails  to  produce  an  adequate  response,  when  there  is 
concealed  bleeding,  or  when  the  placenta  has  not  been 
delivered  and  cannot  be  expressed,  the  uterine  cavity  should 
be  promptly  cleared  out  with  the  fingers.  The  most  careful 
sterilisation  of  the  hands  must  be  practised  before  this  is 
done  and  sterilised  rubber  gloves  should  be  worn.  The 
whole  hand  can  be  introduced  into  the  vagina  immediately 
after  labour  without  causing  the  patient  much  pain,  and  two 
or  three  fingers  can  then  be  passed  into  the  uterus,  and, 
working  in  connection  with  the  other  hand  upon  the  fundus, 
will  readily  clear  out  retained  portions  of  the  after-birth  or 
blood-clot  and  at  the  same  time  powerfully  excite  the  uterus 
to  contract.  Great  cafe  must  be  taken  not  to  overlook  small 
portions  of  adherent  placenta.  When  the  uterus  has  been 
emptied,  a  hot  intra-uterine  douche  can  be  administered,  the 
nozzle  being  passed  and  guided  up  to  the  fundus  before  the 
hand  is  withdrawn. 

All  but  the  most  serious  cases  of  haemorrhage  from 
inertia  can  be  successfully  dealt  with  by  these  means.  In 
the  worst  cases,  which  are  fortunately  very  rare,  these 
methods  may  fail,  and  recourse  must  then  be  had  to  the 
following  modes  of  treatment  : 

(5)  Bi-manual  Compression  of  the  Uterus. — This  can  im- 
mediately be  carried  out  if  evacuation  of  the  uterine  cavity 
followed  by  an  intra-uterine  hot  douche  fails  to  induce 
proper  retraction.  The  whole  hand  is  passed  into  the  vagina, 
and  closed  so  that  the  fist  lies  beneath  the  uterus  ;  the  other 
hand  is  laid  palm  downwards  upon  the  abdominal  wall 
over  the  fundus,  and  the  body  of  the  uterus  is  firmly  squeezed 
between  the  two  hands.  In  this  way  the  placental  site  is 
directly  compressed,  and  bleeding  from  the  utero-placental 
vessels  controlled.  It  may  be  necessary  to  keep  up  this 
form  of  compression  for  a  prolonged  period  while  other 
measures  are  adopted  for  restoring  the  patient,  and  so 
enabhng  the  uterus  to  recover  its  activity.     This  method  is 


524  ABNORMAL   LABOUR 

most  effectual  and  has  superseded  the  old-time  plan 
of  directly  compressing  the  abdominal  aorta  against  the 
lumbar  vertebrae  ;  pressure  apphed  directly  to  the  site 
of  bleeding  is,  of  course,  much  more  effectual  than  com- 
pression of  such  a  large  vessel  as  the  abdominal  aorta. 

(6)  Plugging  the  Uterine  Cavity  with  Gauze.  —  This 
may  be  done  as  an  alternative  to  the  last-named,  or  after 
bi-manual  compression  has  been  apphed  without  complete 
success.  Long  strips  of  gauze,  2  or  3  inches  wide,  and  tied 
together,  can  be  stuffed  into  the  uterus,  beginning  at  the 
fundus  and  tightly  packuig  the  whole  organ  down  to  the 
cervix.  In  plugging  the  uterus  the  cervix  should  be  seized 
with  a  strong  pair  of  volsellum  forceps,  with  which  it  can  be 
easily  pulled  down  to  the  vulva  ;  the  gauze  is  then  intro- 
duced directly  into  the  uterus  with  a  long  probe  or  pair  of 
forceps.  A  very  large  quantity  of  gauze  is  required  to  fill 
the  uterus.  The  best  material  is  gauze  impregnated  with 
oxychloride  of  bismuth ;  this  substance  is  an  antiseptic  of 
more  potency  than  iodoform,  and  the  gauze  can  be  left  for 
a  longer  time  in  the  uterus.  Domestic  substitutes,  such  as 
strips  of  boiled  linen,  may  be  used  in  an  emergency.  The 
uterine  plug  acts  mainly  as  a  powerful  excitant  of  uterine 
contractions  ;  but  it  is  quite  possible  to  pack  the  organ  so 
tightly  as  to  control  haemorrhage  by  direct  pressure.  When 
retraction  has  been  excited,  a  greater  amount  of  direct 
pressure  will  also  be  exerted  by  it.  Bi-manual  compression 
is  more  useful  than  plugging,  because  it  can  be  instantly 
applied,  and  requires  no  assistance  or  apphances.  Plugging 
is  further  subject  to  the  disadvantage  that  complete  asepsis 
is  so  difficult  to  maintain  when  this  method  is  employed. 
Bi-manual  compression  is  therefore  in  all  circumstances 
the  method  of  choice. 

(7)  Methods  of  promoting  thrombosis  in  the  uterine  vessels 
were  formerly  practised,  but  have  now  been  almost  entirely 
abandoned.  The  injection  of  solutions  of  iron  into  the  uterus, 
though  useful  at  the  moment  in  arresting  bleeding,  was 
frequently  followed  by  sepsis.  In  adrenalin  we  now  possess 
a  harmless  haemostatic,  which  can  be  obtained  in  sterile 
solution,  and  it  would  be  sound  treatment  to  swab  the  uterine 
walls  thoroughly  with  this  solution  (1  in  1,000  to  1  in  2,000), 
or  previously  to  soak  in  it  the  gauze  used  for  packing,  in  any 


POST-PARTUM   HEMORRHAGE  525 

case  in  which  complete  control  of  the  bleeding  could  not  be 
obtained  by  other  methods.  Also  its  use  would  be  clearly 
indicated  in  subjects  of  hsemophilia. 

Haemorrhage  from  incomplete  retraction  should  be  treated 
by  the  immediate  removal  of  what  is  retained  in  the  uterus, 
and  then  by  the  same  measures  as  in  the  case  of  inertia. 

B.  Treatment  of  Haemorrhage  from  Lacerations. — 
Lacerations  of  the  vulva  and  lower  parts  of  the  vaginal 
walls  causing  haemorrhage  should  be  immediately  closed  by 
suture,  bleeding  points  being  first  ligatured.  Deep  lacera- 
tions of  the  cervix  and  vaginal  roof  are  not  easily  closed  by 
sutures,  although  with  two  pairs  of  strong  forceps  on  the 
cervix  the  uterus  can  be  drawn  down  a  great  deal ;  it  may 
be  very  difficult  to  reach  the  highest  point  of  the  tear,  and 
if  the  broad  figament  has  been  opened  bleeding  points  may 
be  quite  inaccessible.  Accordingly  many  cases  have  been 
recorded  where  bleeding  has  continued  after  the  laceration 
has  been  apparently  sewn  up.  Two  alternative  methods 
to  suture  may  be  adopted  :  (1)  Bi-manual  compression  ; 
(2)  plugging  with  gauze.  Bi-manual  compression  is 
described  and  practised  by  Fritsch.  He  places  the  closed 
fist  against  the  perineum  and  presses  the  pelvic  floor  deeply 
into  the  pelvic  outlet  ;  owing  to  the  relaxed  and  insensitive 
condition  of  the  parts  this  can  easily  be  done.  The  uterus 
at  the  same  time  is  pressed  firmly  downwards  from  the 
abdomen  with  the  other  hand,  and  thus  the  parts  in  the 
vicinity  of  the  vaginal  roof  can  be  e£fectually  compressed 
between  the  two  hands,  and  the  bleeding  controlled.  For 
plugging  a  laceration  in  the  vaginal  roof  a  speculum  and  a 
good  fight  are  required,  and  this  method  may  therefore  be 
very  difficult  to  apply  in  domestic  practice,  although 
valuable  in  lying-in  hospitals. 

C.  Restorative  Treatment. — ^Although  the  first  indication 
in  treatment  is  to  arrest  the  bleeding,  the  general  condition 
of  the  patient,  in  severe  cases,  also  requires  prompt  attention, 
lest  death  from  syncope  should  occur  after  the  haemorrhage 
has  been  controlled.  While  preparations  are  being  made 
for  the  restorative  measures  described  below,  first  aid  in  a 
serious  case  of  haemorrhage  can  be  given  by  lowering  the 
head  and  holding  up  the  arms  and  legs  in  a  vertical  position, 
and  if  bandages  are  at  hand,  by  bandaging  the  limbs  from 


526  ABNORMAL   LABOUR 

the  feet  or  hands  towards  the  trunk.  In  this  way  blood  is 
conserved  in  the  vital  parts  of  the  body.  The  best  method 
of  immediately  counteracting  the  effects  of  severe  loss  of 
blood  is  the  administration  of  normal  saline  solution  in 
large  quantities.  Even  when  the  patient's  condition  is  not 
urgent,  the  injection  of  a  pint  or  a  pint  and  a  half  of  this 
solution  into  the  rectum  is  the  best  means  of  counteracting 
the  shock  and  relieving  the  thirst  which  always  follow 
severe  haemorrhage.  But  if,  during  or  after  the  bleeding, 
the  patient  is  blanched,  cold,  unconscious,  or  if  her  pulse  is 
over  140,-  transfusion  of  2  pints  of  normal  saline  solution 
into  the  median  basihc  vein  should  be  practised.  There  is 
no  necessity  to  describe  this  simple  surgical  procedure  or 
the  apparatus  required  for  its  performance.  If  the  necessary 
apparatus  is  not  at  hand,  a  useful  alternative  is  to  inject 
the  solution  under  strict  antiseptic  precautions  into  the 
subcutaneous  tissues  with  a  cannula,  a  piece  of  rubber  tubing, 
and  a  funnel.  The  skin  may  be  efficiently  sterilised  by 
painting  it  freely  with  tincture  of  iodine.  A  simple  apparatus 
for  transfusion  occupies  very  Httle  space  in  the  obstetric  bag 
and  should  be  taken  to  every  case  as  a  routine  item  of  the 
armamentarium.  The  most  suitable  positions  for  the  sub- 
cutaneous injection  are  (1)  under  the  mammary  glands, 
(2)  under  the  skin  of  the  posterior  axillary  wall,  (3)  under  the 
skin  of  the  abdominal  waUs.  Salt  should  be  dissolved  in  water 
in  the  proportion  of  about  one  teaspoonful  to  a  pint,  and  the 
solution  boiled  for  ten  minutes  and  then  cooled.  If  there  is  no 
time  for  preparation,  the  salt  may  be  simply  dissolved  in  warm 
previously  boiled  water.  In  the  absence  of  the  necessary 
apparatus  for  transfusion,  the  saline  should  be  injected  into 
the  rectum  ;  not  more  than  one  pint  and  a  half  can  be  given 
at  a  time,  and  the  solution  should  be  slowly  introduced,  pre- 
ferably through  a  tube  and  funnel,  or  the  bowel  will  reject  it. 
The  administration  of  cardiac  stimulants  by  the  mouth 
and  by  hjrpodermic  injection  is  also  of  great  importance, 
and  the  obstetric  bag  should  always  contain  remedies  of 
this  kind.  Strychnine  sulphate,  in  doses  of  3^0  to  -g^  of  a 
grain,  is  a  useful  remedy  for  hypodermic  medication.  Ether 
or  brandy  may  also  be  administered  in  the  same  manner  in 
doses  of  20  to  30  minims.  As  the  researches  of  Blair  BeU 
have  shown,  the  hypodermic  injection  of  an  organic  extract 


ECLAMPSIA  527 

of  the  pituitary  gland  is  the  most  powerful  means  we  possess 
of  temporarily  raising  blood  pressure.  It  may  be  given  in 
doses  of  1  CO.  of  a  20  per  cent,  solution.  Elevating  the  foot 
of  the  bed  for  10  to  12  inches  may  also  assist  the  enfeebled 
circulation.  The  value  of  small  doses  of  morphia  in  con- 
trolling restlessness  after  severe  haemorrhage  should  not  be 
overlooked  ;  a  dose  of  |  to  |^  of  a  grain,  alone  or  in  combina- 
tion with  atropine,  will  relieve  pain  or  restlessness,  and  often 
induce  a  little  sleep,  which  will  be  of  great  benefit  to  the 
patient. 

Labour  complicated  by  Eclampsia 

The  pathology  of  eclampsia  having  been  already  discussed 
(p.  113),  only  clinical  points  wiU  be  here  considered. 

Occurrence. — ^When  the  albuminuria  of  pregnancy  is 
appropriately  treated  it  seldom  terminates  in  eclampsia. 
This  disease  most  frequently  occurs  in  women  who  up  to  the 
time  of  its  onset  have  been  in  apparently  good  health  ;  but 
had  examination  of  the  urine  been  made,  it  is  highly  pro- 
bable that  albumen  would  in  the  majority  of  cases  have  been 
found  before  the  onset  of  the  disease.  A  certain  number  of 
cases  of  eclampsia  have  been  recorded  in  which  no  albumen 
was  found  in  the  urine.  This  is,  however,  very  rare ; 
Olshausen  met  with  it  only  once  in  168  cases.  About 
98  per  cent,  of  cases  occur  after  the  sixth  month  (twenty- 
fourth  week),  but  it  has  been  observed  as  early  as  sixteen  to 
eighteen  weeks,  and  a  number  of  instances  have  been  recorded 
in  which  it  has  occurred  with  a  vesicular  mole,  no  foetus 
being  present  at  aU.  The  convulsions  commence  most 
frequently  before,  or  almost  simultaneously  with,  the  onset 
of  labour  ;  more  rarely  after  labour  has  been  for  some  hours 
in  progress  ;  and  least  commonly  after  labour  is  over. 
Pinard  estimates  the  first-named  at  54  per  cent.,  the  second 
at  30  per  cent.,  the  third  at  16  per  cent,  of  aU  cases.  In 
true  puerperal  cases  the  onset  of  the  convulsions  is  very 
rarely  delayed  for  more  than  forty-eight  hours  after  labour, 
although„  in  some  cases  several  days  have  intervened. 
Labour  complicated  by  eclampsia  is  usually  premature. 
If  there  is  a  history  of  eclampsia  in  a  previous  labour,  the 
presence  of  chronic  nephritis  must  be  suspected. 


528  ABNORMAL   LABOUR 

Clinical  Features. — Although  eclampsia  may  attack  a 
pregnant  woman  who  has  apparently  been  in  good  health  up 
to  the  moment  of  its  onset,  a  series  of  well-marked  symptoms 
sometimes  precedes  its  occurrence.  The  symptoms  associated 
with  the  albuminuria  of  pregnancy  may  have  been  present  for 
some  time  ;  but  in  addition  certain  other  symptoms  often 
occur  which  constitute  what  is  called  the  pre-eclamptic  state. 
They  are  (1)  severe  headache,  usually  frontal,  but  sometimes 
occipital ;  (2)  functional  disturbances  of  vision,  such  as 
muscse  voUtantes,  diplopia,  hemianopsia,  and  temporary 
amblyopia  ;  (3)  occasionally  well-marked  albuminuric 
retinitis,  with  considerable  failure  of  vision  ;  (4)  puffiness  of 
the  eyehds  and  cheeks  ;  (5)  severe  epigastric  pain,  with 
giddiness,  nausea,  or  vomiting  ;  (6)  occasionally,  attacks  of 
petit  mal.  The  condition  of  the  urine  seldom  furnishes 
premonitory  signs,  but  a  sudden  diminution  in  the  total 
amount  of  the  urinary  secretion  may  occur,  and  must  be 
regarded  as  of  great  significance.  In  addition,  the  amount 
of  albumen  may  rise,  the  amount  of  urea  may  fall,  and  the 
proportion  of  ammonia  nitrogen  consequently  become 
increased  (see  p.  109).  Clinical  observations  indicate  that 
a  definite  rise  in  blood-pressure  precedes  the  occurrence  of 
fits.  This  point  has,  however,  not  been  completely  estab- 
lished, but  during  the  stage  of  convulsions  blood  pressure  is 
invariably  raised. 

The  convulsions  are  epileptiform  in  character,  and  con- 
sist of  a  stage  of  tonic,  followed  by  a  stage  of  clonic,  contrac- 
tions. Each  convulsion  is  ushered  in  by  fibrillary  twitchings 
in  the  muscles  of  the  face,  tongue,  and  limbs,  often  followed 
by  conjugate  deviation  of  the  head  and  eyes — ^usually  to  the 
left  side.  Then  comes  a  brief  period  of  tonic  contraction 
in  which  respiration  ceases,  and  the  trunk  may  pass  into 
the  condition  of  opisthotonos  ;  this  is  accompanied  by 
marked  cyanosis,  the  face  being  Uvid,  and  the  tongue 
protruded  between  the  teeth.  This  stage  usually  lasts  less 
than  half  a  minute,  and  gives  place  to  general  clonic  contrac- 
tions which  appear  to  affect  all  the  voluntary  muscles  of  the 
body.  SHght  respiratory  movements  now  occur,  and  the 
cyanosis  gradually  passes  off  during  the  period  of  three  to 
five  minutes  which  this  stage  generally  occupies.  A  varying 
amount  of  mental  disturbance  follows  the  fit  :  in  some  cases 


ECLAMPSIA  529 

the  patient  appears  to  be  merely  sleepy  or  somewhat  dazed 
for  a  few  minutes  ;  in  some  cases  there  is  a  brief  period 
of  coma  ;  in  others  deep  coma  persists,  the  patient  fail- 
ing to  regain  consciousness  before  the  onset  of  the  next 
convulsion. 

The  convulsions  are  almost  always  multiple  ;  they  may 
occur  every  hour,  or  every  half -hour  ;  in  more  serious  cases, 
with  greater  frequency  than  this.  As  many  as  a  hundred  fits 
may  occur  in  a  single  case.  During  the  eclamptic  state  the 
excretion  of  urine  is  greatly  diminished,  and  may  for  some 
hours  be  suppressed  ;  it  frequently  contains  blood,  and 
nearly  always  a  large  amount  of  albumen,  becoming  soUd  on 
boiling.  Suppression  of  urine  is  probably  induced  secondarily 
by  spasm  of  the  renal  arterioles,  which  diminishes  the 
amount  of  blood  circulating  through  the  tissues  of  the 
kidney.  In  all  cases  of  eclampsia  the  urine  must  be 
examined,  the  catheter  being  employed  to  obtain  a  specimen 
if  necessary.  A  high  blood  pressure  is  always  present  in 
fully  developed  eclampsia,  and  readings  of  over  200  mm.  are 
often  met  with.  This  rise  is  generally  beheved  to  be  due  to 
general  arterial  spasm.  When  a  considerable  number  of  fits 
has  occurred,  the  temperature  usually  rises  to  101°  to  102°  F., 
and  in  some  cases  there  is  hyperpyrexia.  Death  may 
result  from  coma,  from  cerebral  haemorrhage,  or  from 
pulmonary  oedema. 

Diagnosis. — It  is  necessary  to  distinguish  the  following 
conditions  from  eclampsia  :  (1)  epilepsy  ;  (2)  hysteria  and 
hystero-epilepsy  ;  (3)  convulsions  or  coma  due  to  cerebral 
disease,  diabetes,  or  acute  poisoning.  Urcemic  convulsions 
are  difficult  to  distinguish  from  eclampsia,  but  the  general 
line  of  treatment  to  be  pursued  is  much  the  same  in  both. 
Cases  of  epilepsy  can  usually  be  recognised  by  the  history 
obtained  from  the  patient  or  her  friends  ;  when  a  history 
cannot  be  obtained,  the  condition  of  the  urine  furnishes  the 
most  rehable  means  of  distinction  ;  but  it  must  be  recol- 
lected that  in  the  rare  cases  of  eclampsia  without  albu- 
minuria the  absence  of  albumen  from  the  urine  will  be 
misleading.  In  general  clinical  features,  the  status  epilep- 
ticus  closely  resembles  a  severe  case  of  eclamptic  coma  with 
elevation  of  temperature.  Cases  of  hysterical  fits,  and  cases 
of  coma  due  to  causes  other  than  renal,  must  be  differentiated 
E.M;  34 


630  ABNORMAL  LABOUR 

by  attention  to  the  special  features  of  these  disorders  into 
which  we  cannot  enter  here. 

Prognosis. — ^The  outlook  in  eclampsia  is  always  very 
serious  both  for  mother  and  child.  The  maternal  mortality 
appears  to  vary  considerably  with  the  severity  of  the  cases 
and  the  method  of  treatment  employed  ;  percentages  are 
of  httle  value  unless  given  in  relation  to  the  same  line  of 
treatment.  The  mortality  is  decidedly  higher  in  multiparas 
than  in  primiparae.  The  greater  the  number  of  fits,  the 
more  serious  is  the  prognosis  ;  in  cases  where  more  than 
twenty  seizures  occur  it  is  said  that  the  mortahty 
is  upwards  of  50  per  cent.  When  the  fits  are  prolonged, 
when  the  temperature  steadily  rises,  and  when  there  is 
early  or  continuous  coma  the  prognosis  is  very  grave  indeed. 
Extreme  degrees  of  anuria  which  do  not  yield  to  treatment 
are  always  of  the  gravest  significance.  Jaundice  is  rarely  met 
with,  but  is  sometimes  present,  accompanied  by  scanty  and 
bloody  urine  ;  a  fatal  termination  must  then  be  expected. 
Yet  the  great  majority  of  mild  cases  of  eclampsia  recover, 
labour  terminating  speedily,  and  the  number  of  convulsions 
not  being  great.  In  severe  cases  which  recover,  prolonged 
mental  disturbance  may  continue,  or  insanity  may  supervene 
in  the  puerperium. 

The  fcBtal  mortality  is  largely  influenced  by  the  period 
of  gestation  ;  in  cases  at  the  twenty-eighth  week  or  earlier  it 
amounts  to  nearly  100  per  cent.,  becoming  less  as  term  is 
approached.  Under  the  most  favourable  conditions  it  is 
probably  as  high  as  40  to  50  per  cent.  The  occurrence  of 
convulsions  in  the  new-born  child,  and  of  post-mortem 
hepatic  lesions  similar  to  those  of  the  mother,  has  been 
already  mentioned.  This  heavy  mortahty  is  to  be  attri- 
buted to  prematurity  and  debihty,  to  intra-uteriae  intoxi- 
cation, to  placental  disease,  and  to  the  effects  of  operative 
interference. 

Treatment. — Severe  cases  tax  the  resources  of  treatment 
to  an  extent  unequalled  in  obstetric  complications.  Only  in 
the  earliest  stages  can  the  disease  be  controlled  with  any 
certainty.  It  is,  therefore,  most  important  that  the  signi- 
ficance of  the  symptoms  of  the  pre-eclamptic  stage  should 
be  clearly  understood,  for  at  this  moment  prompt  treatment 
may  avert  the  convulsions.     When  once  the  convulsions  have 


ECLAMPSIA  531 

begun,  the  patient  should  be  sent  immediately  to  the  hospital 
if  there  is  one  within  reach,  or  in  cases  of  the  better  class 
arrangements  should  be  made  for  continuous  medical  and 
nursing  supervision  of  the  best  and  most  experienced  kind 
which  may  be  available.  If  only  a  single  convulsion  has 
occurred,  there  are  possibilities  of  the  gravest  developments, 
and  no  precautions  must  be  neglected.  A  specimen  of 
urine  should  be  obtained  immediately,  and  complete 
examination  made,  including,  if  possible,  the  tests  for 
acetone  and  diacetic  acid,  estimation  of  the  amount  of 
albumen,  and  a  microscopic  examination  of  the  centrifu- 
gaUsed  deposit. 

General  Principles. — Cases  of  eclampsia  vary  so  greatly 
in  severity  that  no  routine  can  be  followed  in  treating  them. 
The  general  principles  upon  which  treatment  should  be  based 
are  accordingly  of  uncommon  importance,  and  must  be  care- 
fully considered.  These  principles  are  based  upon  the  view 
that  eclampsia  is  a  complex  toxaemia,  the  original  source 
of  which  is  the  placenta  ;  further,  secondary  sources  of 
toxaemia  arise  during  the  course  of  the  disease  from  pro- 
found alterations  in  metabolism  (Hver,  endocrinous  glands), 
and  from  failure  of  the  excretory  functions  of  the  kidneys. 
It  is  not  possible  by  cutting  off  the  original  source  of  the 
toxaemia,  i.e.,  by  emptying  the  uterus,  to  cure  the  disease  in 
every  case,  for  a  lethal  dose  of  toxins  may  be  already  present 
in  the  body  ;  or,  again,  the  structural  damage  sustained 
by  important  viscera,  such  as  the  liver,  may  be  so  great 
that  these  organs  may  fail  to  recover  their  functional 
activity,  so  that  the  existing  toxaemia  is  intensified  and  death 
ensues.  Nevertheless,  the  disease  cannot  be  finally  cured 
until  pregnancy  has  been  ended. 

There  are  accordingly  two  immediate  objects  of  treat- 
ment :  {a)  to  terminate  the  pregnancy  ;  (6)  to  promote  the 
elimination  of  the  toxins,  and  to  neutrahse  their  effects. 
The  relative  importance  attached  by  different  schools  to 
these  two  objects  of  treatment  is  not  the  same.  An  impor- 
tant school  regards  the  first  as  all-important,  and  is,  there- 
fore, prepared  to  subordinate  everything  to  a  rapid  emptying 
of  the  uterus.  To  this  school  the  treatment  of  eclampsia  is 
mainly  a  surgical  problem.  Another  equally  important 
school   regards   the   second   object    as   all-important ;    the 

34—2 


5^2  ABNORMAL  LABOUR 

termmation  of  labour  is  a  secondary  matter,  eliminative 
treatment  is  of  prime  importance,  and  accordingly  to  these 
the  treatment  of  eclampsia  is  mainly  a  medical  problem. 

The  sm'gical  school  encounters  two  practical  difficulties. 
Firstly,  the  subjects  of  profound  toxaemia  are  extremely 
sensitive  to  the  effects  of  surgical  shock,  and  in  many  cases 
the  uterus  can  be  rapidly  emptied  only  by  the  performance 
of  a  serious  operation.  Secondly,  the  toxaemic  symptoms  are 
not  in  all  cases  reUeved  by  the  termination  of  pregnancy  ; 
this  will  be  understood  from  what  has  been  already  said 
about  the  secondary  sources  of  toxaemia.  Herman  has 
shown  that  in  57  per  cent,  of  cases  fits  continue  after  labour. 
And,  again,  in  1'6  per  cent,  of  cases  the  convulsions  do  not 
begin  until  labour  is  over.  Consequently  the  patient  may 
survive  the  operation  of  dehvery  and  yet  die  of  the  disease. 
These  objections  are  met  by  the  surgical  school  with  the  plea> 
that  if  an  early  resort  to  operation  could  always  be  made^ 
i.e.,  before  the  toxaemia  had  become  profound,  these 
difficulties  would  be  largely  avoided. 

The  medical  school  also  encounters  two  difficulties. 
Firstly,  the  effect  of  medical  treatment  is  uncertain,  and  the 
worst  cases  do  not  respond  to  it  at  all.  This  failure  invo  ves 
a  loss  of  time  which  seriously  prejudices  the  success  c  a 
subsequent  operation,  for  the  toxaemia  is  deepening  all  the 
time.  Secondly,  under  the  most  favourable  conditions  this 
treatment  is  paUiative,  not  curative,  and  unless  the  uterus 
is  emptied,  the  source  of  the  specffic  toxins  will  not  be  cut 
off.  Operative  measures  may  therefore  be  required  as 
well. 

One  of  the  chief  practical  difficulties  in  the  treatment  of 
eclampsia  is  that  the  worst  cases  usually  set  in  with  un- 
exampled suddenness  and  severity.  If  an  early  stage  of 
mild  toxaemia  were  always  apparent,  success  by  either 
method  would  be  much  easier  to  attain.  In  point  of  fact, 
the  less  severe  cases  may  be  successfully  managed  by  either 
the  surgical  or  the  medical  plan ;  the  worst  cases  are 
attended  by  a  heavy  mortahty  whatever  treatment  is 
adopted. 

We  may  now  consider  in  more  detail  the  medical  and 
surgical  measures  which  may  be  adopted  in  treating  cases  of 
eclampsia. 


ECLAMPSIA  533 

A.  Medical  Treatment. — The  immediate  objects  of  this 
treatment  are  (a)  to  promote  ehmination ;  (6)  to  neutralise, 
if  possible,  the  effects  of  the  toxins.  The  first  object  is 
much  easier  to  attain  than  the  second.  At  the  same  time 
labour  is  induced  or  its  progress  expedited  by  methods 
which  involve  the  least  possible  shock. 

Eliminative  Treatment. — The  aim  of  eliminative  treat- 
ment is  to  promote  by  all  possible  means  the  elimination  of 
toxic  bodies  from  the  blood  and  from  the  tissues.  The 
methods  which  may  be  employed  are  : 

(a)  Venesection. — From  10  to  15  ounces  of  blood  may  be 
withdrawn  from  the  median  basihc  vein  or  some  other 
source  ;  this  obviously  at  once  reduces  the  total  amount  of 
poison  in  the  blood.  At  the  same  time  it  reduces  blood 
tension,  which  is  always  high  in  toxaemia.  Lichtenstein  has 
recently  attempted  to  show  that  the  apparent  benefit 
following  operative  delivery  in  eclampsia  is  in  reality  due 
to  the  loss  of  blood  which  accompanies  it.  It  is  only 
suitable  for  '  sthenic  '  cases  ;  when  wasting  has  occurred 
or  when  marked  anaemia  and  anasarcfa  are  present  it  is 
contra-indicated. 

(6)  Saline  Transfusion. — This  is  best  carried  out  by  the 
direct  method,  which  consists  in  introducing  from  one  to 
three  pints  of  sterile  saline  solution  through  a  cannula  into 
a  vein.  It  may  conveniently  be  combined  with  venesection, 
the  same  vein  being  made  use  of  for  both  purposes.  The 
immediate  effect  is  to  reduce  the  concentration  of  the  toxins 
in  the  blood  serum  and  thus  to  diminish  their  activity.  In 
eclampsia  a  slightly  alkaline  solution  should  be  used  in  order 
to  neutralise  the  excess  of  acid  bodies  which  are  present  in 
that  condition.  For  this  purpose  30  grains  of  acetate  of 
soda  may  be  added  to  each  pint  of  normal  saline,  as  recom- 
mended by  Jardine.  Other  more  remote  effects  are  that 
diuresis  and,  to  a  less  extent,  diaphoresis  are  produced  ;  in 
other  words,  a  direct  eliminative  effect  is  seen,  but  this  may 
not  appear  for  twenty-four  hours  or  more  after  the  adminis- 
tration. 

Other  methods  of  introducing  saline  solution  into  the 
circulation  may  be  employed,  however,  viz.  subcutaneous 
transfusion,  or  saline  enemata.  Absorption  of  fluid  from 
the  subcutaneous  tissue  is  rapid,  and  also  from  the  rectum 


534  ABNORMAL   LABOUR 

when  empty  ;    but  neither  achieves  such  rapid  results  as 
the  intravenous  method. 

Subcutaneous  transfusion  is  carried  out  with  simple 
apparatus  consisting  of  a  trochar  and  cannula,  a  funnel 
and  tube.  A  Southey's  tube  serves  the  purpose  admirably, 
and  can  be  introduced  without  causing  pain.  The  floor 
of  the  axilla,  the  submammary  region,  and  Scarpa's  tri- 
angle are  convenient  positions  for  it.  Strict  antiseptic 
precautions  must  be  observed,  the  apparatus  being  boiled, 
and  the  skin  painted  with  tincture  of  iodine  ;  even  then 
there  is  a  certain  risk  that  skin  organisms  may  be  carried  into 
the  cellular  tissue,  resulting  in  suppuration,  and  sometimes 
in  sloughing.  Not  more  than  half  a  pint  should  be  intro- 
duced in  one  situation,  and  for  this  amount  to  enter  at  least 
a  quarter  of  an  hour  is  required.  The  fluid  should  be  dis- 
tributed by  pressure  with  the  fingers,  and  undue  tension 
avoided  by  emplojdng  only  a  low  pressure. 

Saline  enetnata  are  rapidly  absorbed  if  the  lower  bowel  is 
empty  ;  but  large  quantities  will  not  be  retained,  and  not 
more  than  a  pint  can  be  introduced  at  a  time.  If  the  enema 
is  repeated  several  times  the  bowel  becomes  intolerant,  and 
rejects  the  whole  or  a  part  of  it.  A  continuous  drop  enema 
(proctoclysis)  may  be  used,  but  the  apparatus  is  difficult  to 
manage  when  convulsions  occur. 

(c)  Diaphoretic  Measures. — Free  action  of  the  skin  is 
of  great  importance  in  aiding  ehmination  and  reducing  blood- 
pressure.  The  hot  blanket  pack  or  the  electric  heat  bath 
are  perhaps  the  quickest  and  best  methods  of  producing 
sweating,  and  should  be  preferred  to  any  others.  Medicinal 
means  are  less  certain,  and  have  the  disadvantage  of  also 
causing  considerable  depression  of  the  circulation.  Pilo- 
carpin  in  doses  of  gr.  jJo  by  hypodermic  injection  usually 
causes  profuse  perspiration,  but  it  greatly  weakens  the 
action  of  the  heart,  and  for  that  reason  cannot  be  adminis- 
tered in  serious  cases.  Antipyretic  drugs  such  as  phen- 
acetin,  antipyrin,  and  salicyhc  acid  are  not  to  be  recom- 
mended. 

{d)  Treatment  of  the  Alimentary  Canal. — It  has  been 
already  stated  that  there  is  reason  to  beheve  that  toxins 
are  freely  excreted  by  the  mucous  membranes  of  the  stomach 
and  intestine  and  may  be  reabsorbed  by  the  colon.     The 


ECLAMPSIA  535 

contents    of    the    alimentary    canal    are    therefore   to   be 
eliminated  as  far  as  possible. 

The  treatment  may  be  begun  by  stomach  lavage ; 
when  the  contents  have  all  been  washed  away  a  full  dose 
of  magnesium  sulphate  in  solution  may  be  left  in  the  stomach. 
Gastric  digestion  appears  to  be  entirely  in  abeyance  in 
severe  cases,  and  nothing  but  water  should  be  given  until 
the  patient's  condition  shows  signs  of  improvement. 
Hastings  Tweedy  has  insisted  upon  this  point,  and  has 
shown  the  excellent  results  of  the  complete  withholding  of 
food  during  the  convulsive  period  of  the  disease. 

Purgation  has  been  employed  empirically  in  eclampsia 
for  many  years.  Saline  aperients  such  as  magnesium 
sulphate,  which  act  chiefly  by  stimulating  the  intestinal 
secretions,  are  the  most  useful.  Purgatives  should  not  be 
administered  to  a  comatose  patient,  for  swallowing  is  then 
very  imperfect,  and  anything  given  by  the  mouth  may  pass  in 
part  into  the  air-passages .  Purging  however  is  not  sufficient. 
Absorption  from  the  intestine  takes  place  chiefly  in  the 
colon,  and  this  part  of  the  bowel  must  accordingly  be  kept 
clear  by  frequent  irrigation.  Normal  saline,  or  the  alkaline 
saline  solution  mentioned  above,  should  be  used  in  large 
quantities  (two  to  three  pints),  a  long  rubber  tube  being 
passed  for  ten  to  twelve  inches  into  the  bowel.  The  colon 
irrigation  should  be  repeated  until  the  large  bowel  is  clear 
of  fsecal  matter. 

(e)  Decapsulation  of  the  Kidneys. — This  operation  has 
been  advised  by  Edebohls  in  severe  cases  of  eclampsia  accom- 
panied by  anuria,  the  object  being  to  restore  renal  activity 
by  relieving  the  renal  circulation  by  allowing  venous  oozing 
from  the  torn  capsular  vessels.  The  operation  consists 
in  exposing  each  kidney  in  the  loin  and,  after  delivering  it 
through  the  wound,  stripping  its  fibrous  capsule  partially 
or  completely  away.  Experimental  observations  have  been 
made  by  Ehrenfest  on  dogs  and  other  animals  ;  he  failed 
to  produce  diuresis  in  healthy  animals  by  decapsulation, 
and  in  some  of  his  experiments  suppression  of  urine  was 
observed.  The  scientific  basis  of  the  operation  is  therefore 
questionable,  and  the  results  of  the  small  number  of  cases 
in  which  it  has  been  performed  are  inconclusive.  Advocates 
of  the  operation  advise  that  it    should   not  be  performed 


636  ABNORMAL  LABOUR 

unless  there  is  extreme  anuria,  and  not  until  it  is  clear  that 
evacuation  of  the  uterus  has  failed  to  reheve  it.  Severe 
cases  of  post-partum  eclampsia  which  do  not  yieldto  palliative 
treatment  have  furnished  most  of  the  opportunities  for  this 
operation.   . 

The  importance  of  restoring  the  renal  functions  in 
eclampsia  is  obvious  and  can  hardly  be  over-stated  ;  after 
the  uterus  has  been  emptied  it  is  the  chief  concern  in  treat- 
ment. Although  a  surgical  measure  it  is  therefore  most 
appropriate  to  consider  decapsulation  as  an  adjunct  to 
eliminative  treatment. 

Treatment  of  the  Toxic  JSymptoms. — It  is  of  the  greatest 
importance  that  the  patient  should  be  isolated  and  all 
avoidable  sources  of  external  irritation — auditory,  visual, 
and  sensory — rigidly  excluded.  There  is  no  doubt  that  the 
onset  of  a  convulsion  may  be  precipitated  reflexly  by  any 
of  the  ordinary  channels  of  sensation. 

During  the  fit  nothing  can  be  done  except  to  prevent  the 
patient  from  injuring  herself.  She  should  be  turned  upon 
her  side  to  allow  the  salivary  secretions,  produced  in  excess 
during  the  convulsions,  to  escape  from  the  mouth,  and  to 
prevent  their  finding  their  way  into  the  air-passages  while 
the  patient  is  unconscious  and  her  reflexes  are  suspended. 
To  save  the  tongue  from  being  bitten  the  best  plan  is  to  fold 
a  handkerchief  in  several  thicknesses,  pass  it  between  the 
teeth  over  the  tongue,  and  hold  it  in  position  until  the  clonic 
contractions  have  ceased  ;  or  a  wooden  plug  or  a  spoon 
handle  covered  with  a  handkerchief  may  be  kept  between 
the  teeth.  The  clothing  should  be  arranged  so  as  not  to 
impede  respiration. 

The  main  object  of  treatment  will  be  to  control  as  far  as 
possible  the  recurrence  of  the  convulsions  by  the  adminis- 
tration of  anaesthetic  or  sedative  drugs  which  directly  influence 
the  central  nervous  system. 

Anaesthetic  or  sedative  drugs  tend  to  prevent  the  periodic 
explosions  of  central  nerve  energy  which  cause  the  convul- 
sions. Of  all  the  drugs  of  this  class  which  we  possess, 
morphia  is  the  most  useful  in  eclampsia,  for  the  reasons 
that  its  effect  is  produced  with  great  rapidity,  and  that  it  can 
be  administered  by  hypodermic  injection  when  the  patient 
is  unable  to  swallow.     Half  a  grain  may  be  given  to  begin 


ECLAMPSIA  537 

with,  and  thereafter  doses  of  a  quarter  of  a  grain  every  two 
or  three  hours  until  two  grains  have  been  given  in  all. 
Next  to  this  the  most  generally  useful  drug  is  chloral  hydrate, 
alone  or  in  combination  with  bromide  of  'potassium.  Thirty 
grains  of  chloral  and  fifteen  grains  of  bromide  may  be  given 
by  the  mouth  every  hour,  until  four  doses  have  been  adminis- 
tered ;  or  they  may  be  given  by  the  rectum,  when  the  dose 
should  be  doubled,  and  the  lower  bowel  must  be  cleared 
out  before  its  administration  is  begun. 

These  sedatives  must  be  used  with  discretion,  and  not 
applied  as  routine  treatment  to  all  cases.  They  are  chiefly 
useful  in  mild  cases — i.e.  those  in  which  the  patient  recovers 
consciousness  more  or  less  completely  between  the  seizures. 
In  severe  cases  accompanied  by  deep  and  continuous  coma, 
little  benefit  is  to  be  anticipated  from  them. 

Treatment  with  morphia  and  chloral  has  been  extensively 
practised  by  StroganofE^  who  makes  these  drugs  the  basis 
of  the  method  known  by  his  name.  He  advises  that 
treatment  should  be  begun  with  a  quarter  of  a  grain  of 
morphia  hypodermicaUy,  followed  one  hour  later  by  30 
grains  of  chloral  by  the  mouth  ;  two  hours  later  the  morphia 
is  repeated,  and  the  chloral  repeated  six  hours  after  the  first 
dose  ;  in  all  four  doses  of  chloral  and  two  of  morphia  may 
be  given  in  twenty-four  hours.  As  soon  as  the  convulsions 
cease  and  the  conditions  are  favourable  labour  is  induced. 
Stroganoff's  own  results  by  this  method  have  been  very 
good;  and  Nagel  has  recently  reported  a  series  of  650  cases 
treated  thus  with  a  maternal  mortality  of  only  8  per  cent. 
Such  favourable  results  have  not  been  obtained  by  the 
majority  of  workers  with  this  method. 

In  France  the  use  of  morphia  is  discountenanced  on 
the  grounds  that  this  drug  tends  to  diminish  the  urinary 
and  other  secretions,  and  that  it  adds  another  form  of 
poisoning  to  those  already  in  existence.  These  objections 
are  mainly  theoretical ;  there  can  be  no  doubt  that  morphia 
in  many  cases  notably  diminishes  both  the  frequency  and 
the  severity  of  the  convulsions,  and  this  is  an  important 
advantage,  for  by  inducing  exhaustion  convulsions  may  be 
the  direct  cause  of  death.  Its  effect  upon  respiration  must 
be  carefully  watched,  for  breathing  may  become  dangerously 
slow. 


538  ABNORMAL   LABOUR 

Another'  metliod  mucli  employed  is  the  administration 
of  chloroform  ;  this  has  been  recommended,  with  certain 
precautions,  in  previous  editions  of  this  book.  Recent 
advances  in  our  knowledge  of  the  nature  of  the  eclamptic 
toxaemia  have,  however,  shown  that  it  has  certain  features 
in  common  with  chloroform  poisoning,  viz.  the  presence 
of  acetonsemia  and  disorganisation  of  the  liver.  The  induc- 
tion of  ansesthesia  by  chloroform  in  persons  not  suffering 
from  toxaemia  sometimes  leads  to  symptoms  of  grave  poison- 
ing from  one  to  three  days  afterwards,  even  in  cases  where 
the  amount  administered  has  not  been  large.  Chloroform 
must,  therefore,  be  regarded  as  a  dangerous  anaesthetic  in 
eclampsia  ;  its  use  should  be  avoided  for  operative  purposes, 
and  it  is  not  advisable  to  administer  it  even  to  produce  a  light 
degree  of  anaesthesia  for  the  control  of  convulsions.  The 
only  general  anaesthetic  used  should  be  ether. 

Treatment  of  Pyrexia. — AntipjTretic  drugs  should  be 
avoided.  If  the  hot  pack  previously  mentioned  fails  the 
body  should  be  rubbed  with  pieces  of  ice. 

The  Circulation. — The  outstanding  features  of  the 
circulation  are  the  rapid  pulse,  the  high  tension,  and  the 
enfeebled  cardiac  action.  Venesection  brings  relief  to  the 
high  tension  ;  intra-venous  transfusion  probably  exaggerates 
it  ;  but  the  general  good  effects  of  the  latter  outweigh  this 
disadvantage.  In  the  United  States  veratrum  viride  has 
been  much  employed  as  a  means  of  reducing  the  pulse  rate 
and  lowering  tension,  and  with  apparent  benefit.  Other 
writers  beheve  that  this  effect  is  accompanied  by  a  depressing 
action  on  the  heart  muscle  which  is  dangerous.  In  reality 
we  have  no  rehable  means  of  directly  assisting  the  circula- 
tion in  eclampsia. 

The  Conduct  of  Labour. — While  medical  treatment  is 
being  carried  out  no  obstetric  interference  is  practised 
except  what  may  be  required  to  assist  the  course  of  a  labour 
already  in  progress.  In  the  majority  of  cases  of  a  mild 
type  the  fits  do  not  begin  until  a  few  hours  after  labour  has 
begun,  and  its  progress  is  rapid  and  easy,  since  the  child 
is  often  premature  and  uterine  action  is  powerful.  The 
confinement  may  then  be  managed  on  general  principles 
except  in  regard  to  two  points  :  (a)  the  second  stage  should 
be  terminated  by  forceps  as  soon  as  the  head  has  passed 


ECLAMPSIA  539 

into  the  pelvic  cavity,  ether  being  used  as  the  anaesthetic  for 
the  reasons  mentioned  above ;  (6)  bleeding  during  the 
delivery  of  the  placenta  may  be  encouraged,  if  venesection 
has  not  already  been  practised.  If  labour  has  not  begun 
one  of  the  slow  methods  of  induction  should  be  practised 
(p.  658).  In  cases  of  post-partum  eclampsia  it  is  obvious 
that  medical  treatment  alone  is  applicable, 
i  We  may  consequently  now  indicate  two  types  of  cases  of 
eclampsia  which  can  be  suitably  treated  by  medical  methods, 
viz.,  mild  cases  in  which  labour  is  in  progress,  and  all  post- 
partum cases.  Mild  cases  occurring  before  the  onset  of 
labour  are  less  favourable,  owing  to  the  uncertainty  of 
methods  of  induction. 

A  difficult  question  which  has  often  to  be  decided  is 
how  long  to  persist  in  palliative  treatment  when  the  results 
achieved  are  negative  or  inconsiderable.  Less  than  twelve 
hours  does  not  allow  sufficient  time  for  definite  effects  to 
appear,  and  the  treatment  should  be  carried  out  thoroughly 
and  continuously  for  that  time.  After  twelve  hours  the 
condition  of  the  patient  and  of  the  uterus  must  decide  the 
question  of  continuing.  If  labour  has  not  begun,  or  is  in 
an  early  stage,  and  the  toxaemia  shows  no  signs  of  lessening, 
surgical  treatment  should  not  be  postponed,  unless  it  is 
definitely  decided  to  reject  it  entirely. 

B.  Surgical  Treatment. — ^The  surgical  treatment  of 
eclampsia  consists  in  effecting  rapid  delivery  when  labour 
has  not  begun,  or  has  only  reached  the  early  part  of  the  first 
stage.  There  are  two  methods  of  rapid  delivery  which  may 
be  made  use  of.  One  consists  in  forcibly  dilating  the  cervix 
and  lower  uterine  segment  until  it  is  large  enough  to  allow 
the  child  to  be  extracted  per  vaginam  ;  it  is  generally  known 
as  accouchement  force,  and  may  be  carried  out  in  several 
different  ways,  which  will  be  described  in  the  section  on 
'  Obstetric  Operations.'  The  other  consists  in  extracting 
the  child  through  an  incision  in  the  uterine  wall  (Caesarean 
section)  ;  it  may  be  done  either  per  abdomen,  by  an  intra- 
peritoneal operation,  or  per  vaginam,  when  the  operation  is 
extra-peritoneal . 

All  these  procedures  are  major  surgical  operations,  not 
to  be  lightly  performed  upon  patients  suffering  from  pro 
found  toxaemia.     Even  when  carried  out  under  some  form 


540  ABNORMAL  LABOUR 

of  local  anaesthesia,  they  produce  a  degree  of  surgical  shock 
which,  in  consideration  of  the  patient's  condition,  appreciably 
increases  the  risk  of  a  fatal  issue.  Nevertheless  in  severe 
cases  the  results  of  ehminative  treatment  are  uncertain,  and 
rapid  evacuation  of  the  uterus  is  the  only  alternative  method 
of  dealing  with  them.  The  indication  for  these  operations  is 
to  save  the  mother ;  therefore  the  condition  of  the  child, 
whether  aUve  or  dead,  is  unimportant. 

Dehvery  by  accouchement  force  is  the  most  severe  of 
all,  and  it  is  not  to  be  recommended.  The  amount  of  shock 
produced  by  rapid  dilatation  of  the  cervix,  by  the  digital 
method,  for  example  (see  p.  668),  is  little  less  than 
that  which  accompanies  Csesarean  section,  and  in  addition 
dangerous  lacerations  of  the  cervix  and  vagina  are  often 
caused  by  these  operations.  Csesarean  section  by  the  abdo- 
minal route  is  the  simplest  and  most  expeditious  method 
we  possess  of  rapidly  evacuating  the  uterus,  and  if  opera- 
tive treatment  is  decided  upon,  this  is  the  operation  of 
choice  for  eclampsia.  Csesarean  section  of  the  full  time 
uterus  by  the  vaginal  route  requires  special  instruments 
and  considerably  more  technical  skill  and  experience  for  its 
performance,  and  is  therefore  only  suitable  for  hospital 
practice.  By  the  abdominal  route  the  operation  can  be 
performed  by  anyone  with  a  Httle  experience  of  abdominal 
surgery. 

If  possible,  operations  in  eclampsia  should  be  performed 
under  spinal  arisesthesia,  or  some  form  of  local  infiltration 
anaesthesia.  If  facilities  for  these  methods  are  not  available, 
ether  given  by  the  open  method  is  the  best  alternative. 

Csesarean  section  has  now  been  performed  fairly  often  in 
eclampsia.  Writing  in  1911,  Peterson  collated  530  cases, 
and  there  is  no  doubt  that  this  operation  is  being  resorted 
to  with  increasing  frequency.  The  operative  risk  no  doubt 
largely  depends  upon  the  duration  of  the  disease  at  the  time 
of  operation  ;  the  earher  it  is  performed  the  more  likely  is 
the  patient  to  recover.  Thus  Winter  has  reported  fifty-six 
early  cases,  some  vaginal,  others  abdominal,  with  only 
three  deaths. 

Choice  of  Methods. — ^Four  types  of  cases  of  eclampsia 
may  be  defined  : — 

(1)  A  mild  case  of  ante-partum  eclampsia  is  suitable  for 


ECLAMPSIA  541 

medical  treatment.  At  the  same  time  means  should  be 
adopted  to  start  labour  if  it  has  not  begun,^or  to  hasten  it  if 
it  is  already  in  progress  ;  the  methods  of  choice  are,  hydro- 
static dilators  for  induction  or  during  the  first  stage,  forceps 
during  the  second  stage, 

(2)  A  severe  case  of  ante-partum  eclampsia  in  which 
labour  is  in  progress  may  be  treated  by  medical  means  for 
twelve  hours,  ehminative  treatment  being  carried  out  fully. 
In  the  absence  of  definite  improvement,  labour  must  then  be 
terminated.  If  the  first  stage  has  advanced,  dilatation  of 
the  cervix  may  be  completed  by  the  digital  method  under 
ether  and  forceps  employed.  If  the  first  stage  has  made 
Uttle  progress,  Csesarean  section  should  be  preferred.  Up  to 
the  thirtieth  week  the  vaginal  operation  may  be  performed, 
as  it  is  then  comparatively  easy.  In  the  absence  of  facilities 
for  performing  this  operation,  rehance  upon  medical  treat- 
ment alone  gives  the  patient  a  better  chance  than  accouche- 
ment force. 

(3)  Post-partum  eclampsia  must  be  treated  by  medical 
means  alone.     Renal  decapsulation  is  not  advised. 

(4)  A  fourth  type  remains,  which  is  the  most  serious  of  all, 
viz.,  that  in  which  severe  toxaemia,  accompanied  by  con- 
vulsions or  coma,  or  it  may  be  by  both,  comes  on  before 
labour  has  begun.  Such  cases  often  occur  with  dramatic 
suddenness  in  women  apparently  in  good  health.  They  do 
not  respond  well  to  ehminative  treatment,  and  loss  of  time 
prejudices  the  chances  of  a  favourable  result  from  surgical 
interference.  They  are  therefore  best  treated  by  Csesarean 
section  without  delay, 

A  '  severe  case '  may  be  defined  for  practical  purposes 
as  one  in  which  any  or  all  of  the  following  conditions  are 
present :  (1)  frequently  recurring  convulsions;  (2)  drowsi- 
ness, stupor,  or  coma  between  the  convulsions  ;  (3)  sup- 
pression of  urine  ;    (4)  pyrexia. 


Part   V 
THE    PUEEPERIUM 

The  Normal  Puerperium 

The  puerperium  is  the  period  succeeding  labour,  during 
which  certain  processes  take  place,  the  effect  of  which  is  to 
restore  the  genital  organs  approximately  to  the  condition 
which  obtained  before  pregnancy.  The  features  charac- 
teristic of  nulliparity  are  never  completely  regained,  for 
certain  of  the  changes  occurring  in  pregnancy,  and  the 
injuries  received  in  labour,  induce  alterations  which  are 
permanent,  although  they  may  vary  greatly  in  degree  in 
different  cases.  The  duration  of  the  puerperal  period  may 
be  stated  as  from  six  to  eight  weeks,  but  it  is  frequently 
longer  than  this.  We  do  not  possess  any  absolute  cHnical 
indication  of  the  completion  of  the  puerperal  changes,  but, 
as  we  shall  presently  see,  the  size  of  the  uterus  is  the  best 
guide. 

Consideration  of  the  normal  puerperium  comprises  the 
following  subjects  : 

(I.)  The  general  physiology  of  the  puerperium. 
(II.)  The  involution  of  the  genital  organs. 

(HI.)  The  management  of  the  puerperium,  including  the 
process  of  lactation. 

I.  The  General  Physiology  of  the  Puerperium. — ^At  the 
close  of  a  normal  labour  the  general  condition  of  the  patient 
is  merely  that  of  physical  fatigue.  The  pulse  is  full  and 
moderately  slow — 70  to  80  beats  per  minute  ;  the  tem- 
perature is  usually  sub-normal.  Not  infrequently  a  slight 
shivering,  marked  by  muscular  tremor  and  chattering  of 
the  teeth,  occurs,  and  may  last  from  ten  to  fifteen  minutes  ; 
it  is  unaccompanied  by  elevation  of  temperature  or  pulse- 
rate,  and  is  to  be  regarded  as  a  symptom  of  slight  surgical 
shock.  Immediately  after  a  prolonged  labour  the  patient 
may  show  signs  of  well-marked  'obstetric  exhaustion,'  with 


GENERAL  PHYSIOLOGY 


543 


a  temperature  of  101°  F.  or  higher ;  and  when  severe 
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paUor,  with  a  rapid  pulse  and  a  lowered  temperature. 

During  the  first  twenty-four  hours  the  temperature  very 
commonly  rises  one  or  two  degrees,  even  after  a  normal 
labour,  and  100°  to  101°  E.  may  in  this  way  be  recorded  with- 
out any  unfavourable  accompaniments.  This  is  especially 
common  in  primiparse.  The  rise  of  temperature  is  to  be 
regarded  as  due  to  the  reaction  from  the  severe  muscular 


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of  Temperature  of  the  Fii-st  Day.     (Queen  Charlotte's  Hospital.) 

Note. — The  interrupted  line  indicates  tlie  height  of  the  fundus  above  the  upper  border  of  the 

symphysis  pubis. 

fatigue  induced  by  labour  ;  it  is  never  prolonged,  and  dis- 
appears entirely  by  the  second  day  (Eig,  261).  After  the 
first  twenty-four  hours  the  temperature  shows  a  diurnal 
variation  of  about  a  half  to  one  degree,  and  in  normal  cases 
it  often  does  not  rise  above  99"4°  E.  In  many  cases,  however, 
which  otherwise  run  a  normal  course,  the  evening  tempera- 
ture for  the  first  few  days  may  reach  99*8°  or  100°  E. 
Instability  of  the  body  temperature  is  one  of  the  charac- 
teristics of  the  puerperium  ;  consequently  variations  occur 
from  causes  too  trivial  to  produce  any  effect  in  health.  The 
temperature  should  be  taken  at  least  three  times  daily, 


544 


THE   PUERPERIUM 


convenient  hours  being  8  a.m.,  2  p.m.,  8  p.m.  ;  if  taken  only 
morning  and  evening,  an  evanescent  rise  may  escape  notice. 
Temporary  elevation  of  the  temperature  to  100°  to  102°  F. 
may  occur  during  the  first  puerperal  week  from  a  number  of 
slight  causes,  such  as  errors  in  diet,  gastro-intestinal  dis- 
turbances, excitement  or  other  nervous  disturbance,  or 
mammary  discomfort  at  the  commencement  of  lactation 
(Fig.  262),  It  appears  certain  that  gastro-intestinal  dis- 
turbances are  responsible  for  many  cases  of  shght  fever 
during  the  first  week.     Hospital  patients  admitted  when 


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Fig.  262. — The  Evanescent  Eise  of  Temperature  on  tlie  Sixth  Day  was 
due  to  Nervous  Excitement.     (Queen  Charlotte's  Hospital.) 

labour  has  advanced  too  far  to  allow  time  for  the  usual 
preparation  by  an  aperient  naturally  show  this  form  of 
pyrexia  more  often  than  others  who  have  been  properly 
prepared.  In  many  other  cases  the  administration  of  a 
purgative  is  immediately  successful  in  bringing  down  the 
temperature,  although  no  other  treatment  is  adopted.  Fever 
from  excitement  is  the  most  evanescent  of  all,  and  lasts 
only  a  few  hours.  The  fourth  day  is  the  time  when  the 
breasts  become  most  severely  distended,  and  rise  of  tempera- 
ture from  this  cause  may  be  met  with.  Primiparse  are  the 
more  hable  to  it,  but  when  suitably  treated  the  fever  seldom 
lasts  more  than  twenty-four  hours.     Pyrexia  from  any  of 


THE   TEMPERATURE  545 

these  causes  does  not  in  an^/  way  disturb  the  general  course 
of  the  puerperium. 

The  significance  of  a  rise  of  temperature  in  the  puer- 
perium is  accordingly  often  obscure  at  first.  Fever  lasting 
for  twenty-four  hours  or  more  is  a  certain  indication  oi 
'  morbidity,'  but  evanescent  rises  of  temperature  are  not 
necessarily  to  be  regarded  as  definite  evidences  of  abnormal 
developments.  Various  standards  of  '  morbidity  '  are  in 
use  in  other  countries,  but  in  this  country  it  has  been 
generally  agreed,  upon  the  suggestion  of  a  committee  of  the 
British  Medical  Association,  to  regard  as  '  morbid  '  all 
cases  in  which  the  temperature  reaches  100°  F.,  or  over,  on 
two  occasions  between  the  second  and  eighth  days.  This 
period  will  not  include  the  reactionary  rise  just  referred  to. 
'  Fever  '  during  the  puerperium,  as  thus  defined,  is  due  in 
the  great  majority  of  instances  to  some  degree — it  may  be 
slight,  it  may  be  severe— of  septic  infection,  and  unless 
some  other  cause  can  be  determined  definitely,  such  cases 
must  be  regarded  and  treated  as  septic.  There  are  but 
few  exceptions  to  the  general  rule  that  an  aseptic  puer- 
perium is  also  afebrile  ;  it  is,  however,  obvious  that  feb- 
rile affections,  quite  independent  of  the  puerperium,  may 
attack  a  lying-in  woman,  although  no  septic  infection  has 
occurred. 

The  pulse-rate  is  usually  slow  (60  to  70)  for  the  first 
twenty-four  to  forty-eight  hours,  and  if  a  reactionary  rise  of 
temperature  occurs,  the  pulse-rate  does  not  rise  with  the 
temperature  ;  it  may  even  fall  as  the  temperature  rises 
(Fig.  261).  After  the  third  day  the  rate  is  about  normal, 
varying  slightly  in  correspondence  with  the  temperature.  In 
patients  anaemic  and  debilitated  from  haemorrhage  the  pulse- 
rate  will  remain  abnormally  rapid  for  several  days.  In  the 
absence  of  such  causes,  a  pulse-rate  continuously  over  90 
is  always  disquieting.  A  rising  pulse  with  a  falling  tempe- 
rature indicates  haemorrhage  ;  when  fever  is  accompanied 
by  a  disproportionately  rapid  pulse,  the  cause  is  usually 
sepsis,  but  the  same  phenomena  may  be  observed  with 
pyrexia  due  to  emotional  disturbance  (Fig.  262). 

The  Excretions. — Great  variations  occur  in  the  amount  of 
urine  excreted  during  the  early  days  of  the  puerperium  ;   it 
appears,  however,  that  the  amount  is,  as  a  rule,  increased  for 
E.M.  35 


546 


THE   PUERPERIUM 


the  first  two  days,  and  then  gradually  falls  until  it  reaches 
the  normal  level.  Sugar  is  normally  present  in  the  urine 
after  the  mammary  glands  have  become  active  ;  it  is  lactose, 
not  glucose,  and  is  derived,  not  from  the  liver,  but  from  the 
mammary  glands.  Peptones  are  present  in  small  amount 
from  the  second  to  the  tenth  day,  and  observers  are  agreed 
in  attributing  them  to  the  involution  changes  going  on  in 


Lower 
uterine 
segment 

Urethral 
brifice 


Fig. 


Promontory 


Placental 
site 


Retraction 
ring 

Rectum 
Cervix 

Pouch  of 
Douglas 

Vag'ina 

1 

Perineal 
body 


263. — Frozen  Section  of  tlie  Pelvis  of  a  "Woman  who  died 
immediately  after  Delivery.     (Barbour.) 


the  uterine  muscle.  Traces  of  albumen  and  acetone  are 
frequently  found,  and  the  percentages  of  urea,  phosphates, 
and  sulphates  are  reduced.  The  act  of  urination  is  at  first 
some\Yhat  painful,  and  temporary  retention  of  urine  may 
occur  either  from  spasm  of  the  sphincter  or  from  paresis  of 
the  muscular  walls  of  the  bladder. 

The  skin  acts  freely,  and  for  the  first  few  days  the  hoivels 
are  usually  constipated. 

Blood, — ^The   deficiency  in  red  cells   and  haemoglobin. 


INVOLUTION 


547 


which  is  natural  in  pregnancy,  is  rapidly  made  up  during  the 
ten  days  following  labour.     The  leucocytosis,  also  natural 


SYMPHYSIS  PUB'S 

URETHRA 


OScXTERHUM 


Fig.  264. — The  Uterus  immediately  after  Delivery,  also  from  a  Frozen 
Section.  The  position  of  the  lower  segment  is  clearly  defined  by  the 
retraction  ring  and  the  thinness  of  the  wall  immediately  below  it. 
The  pelvis  is  contracted  and  the  uterus  is  much  higher  than  normal. 
(Barbour.) 

to  pregnancy,  rapidly  disappears  during  the  same  period, 

the  number  of  white  corpuscles  falling  from  about  21,000 

35—2 


548  THE   PUERPERIIBI 

per  cm.  to  10.000  per  cm.  (Henderson.)  The  diminution 
in  the  number  of  leucocytes  appears  to  bear  some  relation  to 
the  amount  of  the  lochial  discharge,  a  free  discharge  being 
accompanied  by  a  more  marked  fall  than  a  scanty  discharge. 
A  rapid  rise  in  the  number  of  leucocytes  indicates  the  onset 
of  some  septic  or  inflammatory  condition. 

The  digestive  functions  are,  as  a  rule,  depressed  during  the 
first  two  or  three  days,  there  is  little  or  no  appetite,  and  in 
consequence  only  fluid  and  easily  digestible  solid  food  can 
be  taken. 

Bod y-ic eight. — -There  is  a  slight  progressive  loss  of  weight 
during  the  first  ten  days,  which  is  more  marked  in  non- 
nursing  than  in  nursing  women. 

II.  The  Process  of  Involution. — The  ^derus  diminishes 
rapidly  in  size  for  the  first  ten  days,  and  then  more  slowly, 
the  whole  process  requiring  six  to  eight  weeks  for  its  com- 
pletion. According  to  "Whitridge  Williams,  the  uterus  loses 
50  per  cent,  of  its  weight  during  the  first  week  of  the  puer- 
perium.  The  diminution  in  size  can  be  followed  by  abdo- 
minal examination,  and  forms  a  very  important  chnical 
index  of  the  course  and  progress  of  puerperal  involution 
generally.  The  condition  of  the  uterus  immediately  after 
delivery  is  shown  in  the  frozen  section  seen  in  Figs.  263  and 
264.  It  fills  the  pelvic  cavity,  and  at  its  highest  point  rises 
slightly  above  the  level  of  the  sacral  promontory  ;  the  two 
sections  differentiated  from  one  another  during  labour — viz., 
the  body  and  the  lower  segment — are  still  distinct,  and  the 
cervix  is  once  more  distinguishable  from  the  latter.  In 
section  the  wall  varies  in  thickness,  measuring  from  1^  to 
2  inches  (4-5  cm.)  where  it  is  thickest,  to  less  than  \  inch  in 
the  lower  segment,  and  the  uterine  cavity  is  almost  oblite- 
rated by  apposition  of  the  anterior  and  posterior  walls.  Its 
total  length  is  7|-  inches  (20  cm.)  ;  the  length  of  its  cavity  is 
6J  inches  (15*5  cm.).  Clinically  the  uterus  immediately  after 
deliver}^  forms  a  large,  firm,  pyriform  swelling  in  the  lower 
abdomen  rising  up  to  the  level  of  the  umbihcus  (Fig.  260) 
freely  movable,  and  undergoing  slow  variations  in  consis- 
tence. Accurate  study  of  the  rate  at  which  the  uterus 
diminishes  in  size  can  be  made  only  upon  the  cadaver,  and 
Webster  has  collated  the  following  table  from  observations 
of  this  kind  : 


INVOLUTION 


549 


Date 

Whole  Uterus 

Uterine  Cavity 

Immediately  after  delivery 
2nd  day       ..... 
3rd    „ 

eth  „ 

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7|in.  long 

n  „    „ 

6|  „       „ 
3|  „       „ 

6i  in.  long 
6|  „       „ 
5f  „       „ 
4t  „       „ 
3f  ,,       „ 

From  this  it  will  be  seen  that  during  the  first  week  the 
uterus  diminishes  much  more  rapidly  than  during  the  second  ; 
that  the  total  length  diminishes  more  rapidly  than  the 
length  of  the  cavity  owing  to  the  rapid  reduction  in  the 
thickness  and  bulk  of  the  walls  ;  and  that  on  the  fifteenth 
day  it  is  still  very  considerably  larger  than  the  normal  organ 
(cavity  2|  inches,  6  cm.).  Fig.  266  shows  that  on  the  third 
day  the  lower  uterine  segment  is  no  longer  distinguishable 
from  the  rest  of  the  body.  Fig.  267  shows  great  reduction 
in  size  on  the  fifth  day  ;  the  walls  of  the  cervix  are  much 
thinner,  and  numerous  large  solid  thrombi  are  seen  at  the 
placental  site. 

The  rate  of  involution  varies  considerably  in  different 
persons,  even  when  the  conditions  appear  normal.  The 
measurements  given  above  must  therefore  be  regarded  as 
approximate,  not  exact. 

In  making  clinical  observations  attention  is  chiefly 
directed  to  the  height  of  the  fundus  above  the  symphysis 
pubis.  The  results  of  such  observations  necessarily  differ 
from  post-mortem  measurements  of  frozen  sections.  But  it 
must  be  recollected  that  the  position  of  the  uterus  is  largely 
influenced  by  the  condition  of  the  bladder,  and  to  some 
extent  by  that  of  the  rectum.  When  the  bladder  is  full  the 
whole  uterus  is  elevated,  and  usually  displaced  to  one  or 
other  side,  more  commonly  the  right  ;  the  hypogastric 
region  being  occupied  by  a  soft  elastic  swelling,  dull  on  per- 
cussion, and  readily  recognisable  as  the  bladder.  Conse- 
quently, if  daily  measurements  are  made,  they  should  always 
be  made  immediately  after  the  bladder  and  the  bowels  have 
been  evacuated,  so  as  to  ensure  uniformity.  From  careful 
measurements  made  by  Griffith  and  Stevens  at  Queen  Char- 
lotte's Hospital,  it  appears  that  the  average  height  of  the 
fundus  on  the  first  day  is  5^  inches  ;   by  the  sixth  day  it  has 


550 


THE   PUERPERIUM 


fallen  on  an  average  to  3J  inches,  and  by  the  twelfth  day  to 


PLACENTAL       t  —  ^'X 
5/TE      ~ 


POSTERIOR 
VAQINAL  FORNIX 

Fig.  265. — Uterus  40  hours  after  normal  delivery. 
Total  length  7|  inches,  length  of  cavity 
6+  inches.  The  blood  clot  lying  in  the  cavity 
springs  from  the  ragged  area  on  the  anterior 
wall  representing  the  placental  site.  The 
position  of  the  lower  segment  cannot  be 
made  out  and  the  retraction  ring  has  dis- 
appeared.    (Barbour.) 


If  inches  above 
the  pubes.   After 
the      fourteenth 
day  the  fundus, 
as  a   rule,    sinks 
below  the  level  of 
the  pubes  —  i,e. 
into    the    pelvic 
cavity  ;   but  not 
infrequently  this 
does    not    occur 
until  the  end  of 
the   third   week. 
The  rate  of  invo- 
lution, estimated 
in  this    way,     is 
about  the    same 
in  primiparse  and 
multiparse,      but 
in  the  latter  the 
uterus  is   rather 
larger     through- 
out.        Roughly 
speaking,  it  may 
therefore  be  said 
that  at  the  end  of 
the  first  week  the 
fundus  should  be 
halfway  between 
the    pubes     and 
the       umbiUcus, 
and  at  the  end  of 
the  second  week 
just     palpable 
above   the    level 
of  the  pubes. 

The  import- 
ance of  systema- 
tically observing 
the       involution 


INVOLUTION 


551 


of  the  uterus,  as  a  guide  to  the  normal  progress  of  the 
puerperium,    cannot   be   over-estimated.      When   recorded 


\D0UGLA5 

y-^POSTERIOR. 
'  FORHIX 


■0S5XT. 


Fig.  266.— Uterus  two  and  a  half  days  after  delivery;  top  of  the  fundus 
reaches  three  inches  above  the  pubes.  The  placental  site  is  at  the 
fundus.     (Barbour.) 

upon  the  temperature-chart  in  the  manner  indicated  in  Figs. 
261  and  262,  it  supplies,  along  with  the  temperature-curve, 
important  information  as  to  the  general  progress  of  the 


552 


THE   PUERPERIUM 


patient.  There  are  a  number  of  conditions  which  unfavour- 
ably influence  the  rate  of  involution  of  the  uterus.  Thus,  in 
multiparas  it  is  found  that  after  five  or  six  pregnancies  have 
occurred,  involution  requires  appreciably  longer  than  the 
average.  When  the  uterus  has  been  unusually  large,  as  in 
hydramnios  or  twins,  when  there  has  been  severe  ante-  or 
post-  partum  liEemorrhage,  and  when  the  woman  does  not 


Pig.  267. — Frozen  Section  of  the  Pelvis  of  a  Woman  who  died  five 
days  after  Delivery.     (Bumm.) 


suclde  her  child,  involution  is  delayed.  The  retention  of 
tissue  in  the  uterus,  especially  if  it  should  become  infected, 
delays  involution,  but  this  does  not  occur  with  all  varieties 
of  uterine  infection  (see  p.  569). 

Structural  Changes  in  the  Uterus. — Very  careful  measure- 
ments of  the  fibres  of  the  uterine  muscle  during  the  puer- 
perium  have  been  made  by  Sanger  ;  he  found  that  in  length 
they  diminish  rapidly  and  at  a  fairly  uniform  rate,  until  at 
the  fifth  week  the}^  are  actually,  shorter  than  in  the  non- 


INVOLUTION  553 

pregnant  organ  ;  in  breadth  they  increase  during  the  first 
few  hours  by  retraction,  and  then  steadily  diminish  until  at 
the  fifth  week  they  are  only  a  trifle  broader  than  before 
pregnancy.  Fatty  degeneration  has  also  been  described  in 
the  muscle  fibres  by  numerous  observers,  and  there  is  no 
doubt  that  it  forms  a  constant  and  important  feature. 
Helme  has  described  in  the  rabbit's  uterus  a  process  of 
degeneration,  which  he  believes  to  be  due  to  peptonisation 
of  the  protoplasm  of  the  muscle  cells  ;  and  associated  with 
it  he  found  multinucleated  plasmodia  (phagocytes)  among 
the  degenerating  fibres,  engaged,  as  he  believed,  in  absorbing 
them.  Destruction  of  muscle  by  phagocytosis  has  never 
been  demonstrated  in  the  human  uterus,  and  it  is  generally 
held  that  fatty  degeneration  and  peptonisation  are  the 
processes  chiefly  concerned.  In  this  connection  it  will  be 
recollected  that  peptones  are  present  in  the  urine  of  puer- 
peral women. 

The  Uterine  Vessels. — The  involution  changes  in  the 
vessels  have  been  studied  by  Goodall.  This  observer 
has  shown  that  to  a  great  extent  the  old  vessels  first 
become  obliterated  by  thrombosis  and  then  undergo 
degenerative  changes  and  disappear,  while  new  vessels  are 
formed  to  replace  them.  Further  he  has  demonstrated  the 
appearance  of  new  vessels  of  small  size  in  the  organising  clot 
formed  in  the  lumen  of  the  obliterated  vessels.  The  walls  of 
the  old  vessels  undergo  gradual  degeneration  and  absorption, 
new  connective  tissue  growing  in  from  the  uterine  wall  to 
replace  them  and  support  the  small  newly  formed  vessel. 
This  change  occurs  alike  in  arteries  and  veins,  and  the  new 
vessels  are  complete  in  structure,  consisting  of  the  usual 
three  coats.  Absorption  of  the  walls  of  the  old  vessels  is 
often  incomplete,  and  a  process  of  degeneration  occurs, 
converting  the  remains  into  '  elastin,'  a  substance  with 
characteristic  staining  reactions.  The  recognition  of  scattered 
areas  of  this  substance  is  therefore  equivalent  to  a  diagnosis 
of  parity,  and  in  the  condition  known  as  sub -involution 
(imperfect  involution)  elastin  is  present  in  excess  (Fletcher 
Shaw). 

The  Uterine  Mucosa. — A  considerable  portion  of  the 
cavernous  layer  of  the  decidua  remains  attached  to  the 
uterine  wall  ;  but  here  and  there  bare  patches  of  the  muscular 


554  THE   PUERPERIUM 

wall  may  be  seen.  The  membrane  is  furrowed  and  folded 
by  the  retraction  of  the  subjacent  muscle,  and  soon  becomes 
covered  with  a  layer  of  fibrin.  In  seven  to  eight  weeks  the 
mucous  membrane  is  entirely  re-formed  by  proliferation 
of  the  remaining  epithelial  and  connective-tissue  elements. 
When  the  puerperal  uterus  of  the  first  week  is  laid  open,  the 
placental  site  may  be  readily  distinguished,  as  its  surface 
is  slightly  elevated  and  nodular,  the  irregularities  being 
chiefiy  caused  by  the  extensive  thrombosis  which  has 
occurred  in  the  sub-placental  sinuses  (Figs.  266  and  267). 
Outside  the  placental  site  the  wall  is  smooth  and  uni- 
form. 

The  Lochial  Discharge. — This  is  the  discharge  which 
escapes  from  the  genital  canal  during  the  first  two  to  three 
weeks  of  the  puerperium.  For  the  first  twenty-four  hours 
it  consists  of  blood,  mostly  fluid,  but  frequently  containing 
small  clots  ;  it  then  becomes  thinner,  though  still  of  the 
colour  of  recent  blood.  About  the  third  or  fourth  day  it 
becomes  brownish  ;  by  the  end  of  the  first  week  it  is  yellowish 
or  greenish  ;  and  then  gradually  loses  all  colour,  being 
white  and  turbid  until  its  final  disappearance.  Besides  red 
blood  cells  and  fibrin,  it  contains  leucocytes,  decidual  debris, 
vaginal  epithelium,  mucus  corpuscles,  and  in  the  later 
stages  pus  cells.  Peptones  and  cholesterin  crystals  have 
also  been  found  in  it.  According  to  Giles,  the  amount  of 
the  lochia  is  greater  than  normal  after  haemorrhage  during 
labour,  and  is  habitually  greater  in  women  of  dark  com- 
plexion than  in  blondes,  and  in  those  who  lose  freely  during 
menstruation  than  in  those  whose  menstrual  loss  is  scanty. 
It  is  a  common  observation  that  when  the  uterine  cavity 
has  been  douched  after  labour  the  amount  of  lochial  dis- 
charge is  always  less  than  normal. 

Throughout  a  normal  afebrile  puerperium,  in  the  uterus 
the  lochia  are  alkaline  in  reaction,  and  usually  have  a  faint 
sickly  odour  ;  in  the  vagina  they  become  acid,  and  after 
the  first  few  days  usually  contain  numerous  non-pathogenic 
bacteria.  The  bacterial  condition  of  the  lochia  has  been 
the  subject  of  many  contradictory  observations,  and  certain 
points  are  still  unsettled.  It  appears  certain,  however, 
that  in  the  vagina  the  lochial  discharge  does  not  remain 
sterile  for  more  than  twenty-four  hours,  while  in  the  cervix 


THE  LOCHIA  555 

bacteria  can  always  be  found  after  the  second  or  third 
day.  The  conditions  in  the  body  of  the  uterus  are  much 
more  difficult  to  determine  owing  to  the  technical  difficiilty 
of  obtaining  lochia  from  the  uterine  cavity  without  con- 
tamination from  the  cervix  and  the  results  obtained  have 
not  been  uniform,  Foulerton  and  Bonney  have  shown 
that  with  proper  technique  no  bacterial  growth  can 
be  obtained  from  the  uterus  in  a  large  proportion  of 
normal  cases,  but  their  series  was  too  small  to  permit 
of  percentages  being  calculated.  It  is  probable  that 
the  positive  results  obtained  in  a  large  proportion  of 
cases  by  others  have  been  due  to  faults  of  technique  per- 
mitting of  cervical  contamination.  We  may,  therefore, 
regard  it  as  highly  probable  that  in  the  normal  puer- 
perium  the  uterine  cavity  remains  sterile  for  several  days. 
Under  morbid  conditions  the  lochia  may  be  suddenly 
suppressed,  or  may  become  foetid  from  infection;  or  may  be 
altered  by  fresh  haemorrhage.  When  involution  is  delayed, 
they  may  persist  longer  than  usual,  although  not  abnormal  in 
characters.  The  source  of  the  lochial  discharge  is  mainly 
the  uterine  cavity,  but  cervical,  vaginal,  and  vulval  lacera- 
tions also  contribute  to  it  to  some  extent. 

After-pains. — In  multiparse  the  normal  puerperium  is 
usually  accompanied  for  the  first  one  or  two  days  by  painful 
contractions  of  the  uterus,  which  are  known  as  after-pains. 
These  when  slight,  are  probably  of  service  in  maintaining  the 
necessary  close  retraction  of  the  uterine  wall,  and  they  require 
no  treatment.  Severe  after-pains  are  usually  due  to  the 
presence  of  some  foreign  body,  such  as  a  blood-clot  or  a  piece 
of  membrane  or  placenta.  Trom  imperfect  retraction 
blood-clot  may  form  in  the  uterine  cavity  even  after  it  has 
been  completely  emptied  at  the  end  of  the  third  stage  ;  this 
is  much  more  likely  to  occur  with  a  multipara  than  with  a 
primipara,  for  retraction  is  usually  adequate  in  primiparse. 
But  when  the  uterus  is  not  empty,  after-pains  may  be  met 
with  in  a  primipara  just  as  in  a  multipara.  They  should  be 
treated  by  stimulating  the  uterus  to  expel  the  foreign  body. 
This  may  be  done  by  giving  a  teaspoonful  of  liquid  extract 
of  ergot  every  four  hours,  by  massaging  the  uterus  per 
abdomen,  and  by  a  hot  vaginal  douche  (115° — 118°  F.)  of 
boiled  water,  or  a  mild  antiseptic,  such  as  lysol,  a  teaspoonful 


556  THE   PUERPERIUM 

to  a  quart.  The  expulsion  of  a  blood-clot  usually  follows  iii 
a  few  hours,  revealing  the  cause  of  the  trouble, 

'Severe  after-pains  sometimes  occur  with  a  completely 
retracted  and  empty  uterus  ;  we  do  not  know  what  may  be 
the  exciting  cause  of  the  painful  contraction  in  such  cases. 
Pains  of  this  character  can  usually  be  cured  by  administering 
a  dose  of  antipyrin  (10  grains),  which  should  be  given  with  a 
stimulant,  such  as  20  to  30  drops  of  sp.  ammoniae  aromat. 

III.  Management  of  the  Puerperium. — There  are  three 
objects  to  be  kept  in  view  in  the  management  of  the  lying-in 
woman  :  (1)  to  maintain  asepsis  in  the  genital  canal  ; 
(2)  to  enforce  a  sufficient  period  of  rest  ;  (3)  to  regulate  the 
function  of  lactation. 

(1)  Asepsis. — If  the  antiseptic  precautions  observed 
during  labour  have  been  successful,  the  genital  canal  will  be 
sterile  at  the  commencement  of  the  puerperium  ;  and  the 
principal  care  of  doctor  and  nurse  is  to  prevent  infection  from 
reachmg  it.  The  greatest  possible  care  must  accordingly 
be  taken  of  the  vulva.  The  lochial  discharge  should  be 
received  upon  sterilised  pads  of  absorbent  wool  or  gauze, 
or  these  substances  impregnated  with  an  antiseptic  such  as 
corrosive  sublimate  ;  the  pads  should  be  removed  and  burned 
as  soon  as  they  become  soiled.  During  the  first  three  or 
four  days  the  vulva  should  be  frequently  swabbed  with  a 
solution  of  lysol  (5j  to  Oj).  It  is  essential  that  the  nurse's 
hands  and  all  the  appliances  used,  such  as  catheters  and 
vaginal  nozzles,  should  be  as  carefully  sterihsed  during  the 
puerperium  as  during  labour. 

Vaginal  douching  is  unnecessary  when  the  puerj)erium 
runs  a  normal  course.  The  aim  of  management  should  be  to 
preserve  the  genital  tract  from  contammation,  rather  than  to 
endeavour  to  destroy  organisms  which  may  have  gained 
access  to  it.  No  amount  of  vaginal  douching  can  compen- 
sate, for  instance,  for  careless  treatment  of  the  vulva. 
Vaginal  douching,  in  addition  to  being  unnecessary,  may 
become  positively  dangerous,  when  carried  out  carelessly 
or  by  untrained  persons,  by  introducing  into  the  vagina 
organisms  which  would  not  otherwise  obtain  access  to  it. 
Routme  vaginal  douching  has  accordingly  been  almost 
universally  abandoned.  Yet  there  is  little  doubt  that  the 
mechanical  clearing  of  the  vagina  by  the  douche  is  comfort- 


MANAGEMENT  557 

ing  to  the  patient,  and  prevents  stagnation  of  the  lochia  in 
the  vaginal  fornices — a  condition  very  apt  to  occur  while 
the  patient  continuously  maintains  the  recumbent  position. 
These  advantages  are,  however,  not  of  sufficient  importance 
to  outweigh  the  attendant  risks.  Decomposition  of  the 
lochia,  indicated  by  foetor,  is  the  most  frequent  indication 
for  the  douche  in  an  afebrile  puerperium,  and  a  solution 
of  1  in  4,000  of  biniodide  or  perchloride  of  mercury  is  the 
best  solution  to  employ  under  these  circumstances.  Hot 
antiseptic  or  sterile  douching  may  also  be  required  for  the 
control  of  puerperal  haemorrhage,  or  to  promote  the  expul- 
sion of  blood-clot  or  membrane  retained  in  the  uterus. 

Other  antiseptics  which  may  be  employed  for  vaginal 
douching  are  lysol,  izal  or  cyllin  (5j  to  Oj),  or  carbolic 
acid  (1  in  60).  A  solution  of  iodine  (5j  of  tinct.  iodi  to  Oj 
of  water)  may  also  be  used,  and  is  frequently  employed 
as  an  intra-uterine  douche,  on  account  of  its  non-poisonous 
nature.  When  douching  the  uterus  in  the  early  puerperium 
the  same  solutions  may  be  employed  in  one-half  the  strength 
used  for  the  vagina.  Although  these  solutions  are  useful  for 
douching,  in  sterilising  the  skin  mercurial  solutions  are  much 
more  efficient  than  any  others.  It  must  be  remembered 
that  by  the  indiscriminate  use  of  mercurial  douches  acute 
mercurial  poisoning  may  be  set  up,  and  some  such  cases 
have  proved  fatal.  The  symptoms  of  mercurial  poisoning 
from  absorption  are  the  same  as  those  produced  when  the 
poison  is  taken  by  the  mouth — viz.,  vomiting,  diarrhoea, 
salivation,  acute  gingivitis  ;  sometimes  in  fatal  cases 
patches  of  sloughing  in  the  mucous  membrane  of  the  colon 
have  been  found. 

When  a  perineal  laceration  has  been  sutured  the  wound 
should  be  kept  clean  and  covered  with  strips  of  lint  spread 
with  boric  acid  ointment ;  the  ointment  should  be  re- 
sterilised  daily  by  boiling  the  pot  containing  it. 

A  well-ventilated  room  free  from  risk  of  contamination 
from  faulty  drain-pipes,  and  clean  fresh  bed-linen  and  bed- 
garments,  are  valuable  aids  to  the  maintenance  of  asepsis  ; 
yet  in  the  homes  of  the  poor,  where  these  desiderata  cannot 
be  obtained,  the  local  precautions  indicated  will  succeed,  in 
all  but  a  few  cases,  in  preventing  infection. 

(2)  Rest. — Rest  in  bed,  but  not  necessarily  in  the  hori- 


558  THE   PUERPERIUM 

zontal  position,  should  be  maintained  until  the  uterus  has 
sunk  below  the  symphysis  pubis  and  the  lochial  discharge 
has  become  colourless.  When  ordinary  avocations  are 
resumed  with  the  uterus  as  large  as  it  is  on  the  tenth  day 
of  the  puerperium,  it  is  clear  that  there  must  be  liability 
to  prolapse,  retroversion,  and  sub -involution.  The  poor 
habitually  neglect  this  precaution,  but  there  is  little  doubt 
that  they  suffer  in  consequence.  After  the  first  forty-eight 
hours  the  patient  may  be  propped  up  with  pillows  or  a  bed- 
rest, and  this  position  is  of  advantage  in  promoting  the  escape 
of  the  lochia.  Light  and  nourishing  food,  both  solid  and 
fluid,  may  be  given  freely  during  the  first  two  days  ;  an 
aperient  should  be  administered  on  the  evening  of  the  second 
day,  and  after  this  ordinarj^  food  may  be  taken.  The  action 
of  the  bowels  is  usually  sluggish  while  the  patient  is  confined 
to  bed,  and  a  daily  mild  aperient  may  be  required,  or  an 
enema  if  the  latter  will  suffice.  The  condition  of  the  bladder 
must  be  carefully  watched  during  the  first  two  days  ;  if 
retention  occurs  resort  should  not  be  had  to  the  catheter 
until  means  of  procuring  spontaneous  evacuation  have  been 
tried.  The  strictest  antiseptic  precautions  are  required  for 
this  simple  procedure.  Occasionally  the  bladder  is  im- 
perfectly evacuated  by  the  natural  efforts  and  becomes 
gradually  over-distended,  causing  great  discomfort.  This 
condition  will  be  recognised  by  careful  abdominal  examina- 
tion. Emotion  and  excitement  may  produce  alarming  rises 
of  temperature  in  Ijdng-in  women  ;  therefore,  in  private 
practice,  patients  should  be  practically  isolated  for  the  first 
few  days.  Sleep  almost  always  comes  naturally  to  a 
lying-in  woman,  but  hypnotic  drugs  should  be  given  without 
hesitation  if  sleep  is  absent  or  insufficient,  for  sleeplessness 
may  be  a  prelude  to  serious  mental  complications. 

In  the  case  of  patients  who  are  able  to  afford  it,  general 
massage  by  a  skilled  person  may  be  used  with  great  benefit 
after  the  first  week.  This  aids  digestion  and  promotes  the 
natural  action  of  the  bowels,  improves  the  general  condition, 
which  is  apt  to  suffer  from  muscular  inaction,  and  by  improv- 
ing the  tone  and  condition  of  the  abdominal  muscles  helps 
to  restore  these  structures,  which  have  necessarily  suffered 
from  stretching  in  pregnancy.  To  women  who  set  store 
upon  their  '  figure  '   this   also    a  point   of   some    aesthetic 


MANAGEMENT  559 

importance.  Permanent  loss  of  power  of  the  abdominal 
muscles  is  in  all  probability  an  important  predisposing  cause 
of  displacement  of  the  pelvic  and  abdominal  viscera. 

The  '  Rational '  Puerperium. — Under  this  somewhat  mis- 
leading name  an  attempt  has  been  made  to  show  that 
it  is  inadvisable  to  keep  women  in  bed  for  more  than 
two  days  after  labour,  and  that  they  will  be  benefited  by 
being  encouraged  to  get  up,  and  sit  up  or  walk  about,  when- 
ever the  obstetric  conditions  are  in  all  respects  normal. 
The  main  reasons  assigned  for  this  innovation  are  that 
pregnancy  and  labour  are  not  morbid  but  physiological 
processes,  and  that  primitive  or  uncivilised  woman  does  not 
observe  a  lying-in  period  and  apparently  does  not  require 
it.  The  name  given  to  this  method  of  management  is 
unfortunate  and  regrettable,  inasmuch  as  it  introduces 
prejudice  by  implying  that  the  alternative  method  is 
irrational.  The  reasons  assigned  for  regarding  the  method 
as  '  rational '  hardly  deserve  consideration,  for  if  pregnancy 
and  labour  are  not  morbid  processes  they  are  attended  by 
greater  risks  and  may  be  followed  by  more  serious  sequelae 
than  many  recognised  diseases.  The  example  of  the  un- 
civilised woman,  also,  is  not  in  all  respects  to  be  enjoined 
upon  others  ;  she  does  not  practise  the  use  of  antiseptics  in 
labour,  but  we  do  not  for  that  reason  regard  them  as 
irrational.  The  advocates  of  this  form  of  management  of  the 
puerperium  have  undoubtedly  shown  that  no  immediate  ill- 
effects  follow  from  allowing  a  lying-in  woman  to  get  up  and 
walk  about  at  an  earlier  period  than  has  usually  been  thought 
desirable.  Whether  these  women  suffer  more  than  others 
from  the  remote  ill-effects  of  child-bearing  has  not  yet  been 
shown. 

(3)  The  Process  of  Lactation. — By  lactation  is  meant  the 
establishment  of  functional  activity  in  the  mammary  glands. 
Certain  signs  of  activity,  which  have  been  already  described, 
are  present  in  the  breasts  during  the  greater  part  of  the 
period  of  pregnancy.  For  forty-eight  hours  after  delivery  no 
further  change  takes  place  ;  during  the  third  day  the  breasts 
undergo  rapid  enlargement,  becoming  tense,  nodular,  and 
often  very  tender  to  the  touch,  the  skin  being  tense  and 
glistening.  On  the  fourth  day  the  condition  of  distension 
reaches  its  height  and  is  more  severe  in  a  primipara  than  a 


560 


THE  PUERPERIUM 


multipara.  The  breasts  are  then  full  of  thick  yellow  secre- 
tion which  can  be  readily  expressed,  or  may  escape  spon- 
taneously from  the  nipple.  During  the  first  week  the  secre- 
tion is  known  as  Colostrum.  Considerable  local  pain  and 
general  discomfort  usually  attend  the  '  coming  of  the  milk,' 
and  a  rise  of  one  or  two  degrees  of  temperature  may  occur  for 
a  few  hours.  Suckling  and  spontaneous  overflow  speedily 
relieve  the  overdistension  of  the  glands,  and  in  one  or  two 
days  all  symptoms  of  discomfort  disappear,  although  active 
secretion  will  continue  for  many  months.     After  suckling 


ColostTUra 
corpuscles 


Fat 
globules 


EpitKelium. 


Fig.  268.— The  Elements  of  Human  Milk  (Colostrum). 
(^Bumm.) 

for  two  or  three  days  the  secretion  becomes  thinner  and 
less  yellow.  The  mammary  secretion  is  established  some- 
what sooner  in  a  multipara  than  in  a  primipara,  and  the 
initial  distension  is  less  severe. 

Colostrum  possesses  certain  special  features  which  are 
sometimes  of  forensic  importance  as  evidence  of  recent 
dehvery.  Its  naked-eye  appearances  have  been  indicated  ; 
under  the  microscope  it  is  seen  to  contain,  besides  the  poly- 
morphous fat-globules  characteristic  of  milk,  certain  special 
elements  which  have  been  named  colostrum  corpuscles.  These 
are  leucocytes  containing  large  droplets  of  fat.     Epithelial 


BREAST    FEEDING  561 

cells  in  a  more  or  less  advanced  state  of  fatty  degeneration, 
which  have  been  detached  from  the  walls  of  the  glandular 
acini,  are  also  seen  (Fig.  268).  They  disappear  after  the  first 
few  days  of  suckling.  The  anatomy  of  the  function  of  lacta- 
tion is  fully  described  in  text-books  of  physiology,  and  need 
not  be  referred  to  here. 

The  composition  of  human  milk  will  be  referred  to  in 
connection  with  Artificial  Feeding  (p.  621). 

The  child  cannot  be  fed  regularly  from  the  breast  until 
the  secretion  becomes  fully  established  about  the  third  day. 
During  the  first  two  days  it  may  be  allowed  to  draw  what  it 
can  from  the  breasts  occasionally  ;  probably  more  food  will 
not  be  required  than  it  can  thus  obtain,  but  if  hunger  is 
indicated  by  restlessness  and  crying,  small  quantities  of 
boiled  water  or  of  diluted  cow's  milk  may  be  given  in  addition 
(see  Infant  Feeding).  It  is  necessary  to  prepare  the  nipples 
carefully  for  the  process  of  suckling  during  the  last  few  weeks 
of  pregnancy,  especially  in  the  case  of  a  primigravida.  The 
skin  of  the  nipples  and  areolae  should  be  cleansed  once  or 
twice  daily,  bathed  with  boric  acid  lotion  1  in  40,  and  a  mild 
antiseptic  ointment,  such  as  boric  acid  and  white  vaseline 
(1-40),  gently  rubbed  into  it.  If  the  nipples  are  depressed 
a  breast-pump  may  be  used  to  draw  them  out,  and  with  the 
additional  help  of  frequent  gentle  manipulation,  exciting 
the  reflex  erection  of  the  nipple  by  its  muscles,  the  depression 
can  usually  be  overcome. 

After  the  third  day  the  infant  should  be  fed  from  the 
breast  at  regular  intervals  of  two  hours  during  the  day  and 
three  or  four  hours  during  the  night.  If  the  breasts  should 
become  painful  from  overdistension  and  the  temperature 
raised,  hot  fomentations  should  be  applied,  and  the  breasts 
gently  massaged,  rubbing  towards  the  nipple.  At  this  stage 
the  ducts  sometimes  become  partly  blocked,  impeding  the 
escape  of  the  secretion,  and  on  the  removal  of  the  obstruction 
the  pain  and  distension  disappear. 

In  giving  the  breast,  great  care  should  be  taken  to  adjust 
the  mother's  position  so  that  the  child  can  reach  the  nipple 
comfortably  without  having  to  turn  or  stretch  its  neck  in  the 
attempt.  Difficulty  in  getting  the  child  to  take  the  breast  is 
often  due  to  neglect  of  this  simple  precaution.  In  ten  to 
fifteen  minutes  enough  will  usually  have  been  obtained  to 
E.M.  36 


562  THE   PUERPERnBI 

satisfy  the  child,  and  it  will  then  fall  asleep  or  cease  to  suck. 
After  each  feed  the  mouth  should  be  cleansed  with  a  piece  of 
cotton-wool  dipped  in  boric  lotion  ;  this  is  required  because 
a  Httle  milk  accumulates  in  the  cheeks,  where  it  will  ferment 
if  allowed  to  remain,  and  give  rise  to  digestive  disturbances, 
or  to  thrush.  The  nipples  must  also  be  cleansed  with  boric 
lotion  and  carefully  dried  every  time  the  child  has  been  fed. 
A  piece  of  clean  lint,  or  preferably  a  small  pad  of  sterihsed 
cotton,  should  be  kept  applied  to  the  nipple,  and  the  breasts 
lightly  supported  by  a  binder.  In  this  way  the  nipples  can 
be  protected  from  mfection,  and  the  occurrence  of  mastitis 
prevented. 

Cracked  or  Sore  Nipples. — Primiparse  frequently  suffer 
from  the  formation  of  fissures  of  the  nipple  at  the  commence- 
ment of  the  process  of  suckling.  They  may  occur  either  at 
the  apex  or  the  base,  and  in  the  latter  position  are  sometimes 
overlooked.  They  begin  as  slight  abrasions  caused  by  the 
gums  of  the  child,  or  by  the  vigorous  use  of  its  buccinator 
muscles.  If  the  secretion  is  scanty,  or  if  the  child  is  allowed 
to  take  the  breast  before  any  secretion  can  be  obtained, 
unusually  vigorous  suction  will  be  made,  and  abrasions  may 
thus  be  formed  upon  the  nipple.  Such  abrasions  are  often 
seen,  but  as  a  rule  they  give  rise  to  Httle  paui  and  heal 
spontaneously  in  twenty-four  to  forty-eight  hours.  They 
maj^  however,  become  infected,  giving  rise  to  fissures. 
These  render  the  process  of  suckhiig  extremely  painful,  and 
may  lead,  if  neglected,  to  the  formation  of  a  mammary 
abscess.  If  at  aU  deep  they  bleed  during  suckling,  and  the 
blood,  being  swallowed  along  ^^'ith  the  milk,  may  later  on  be 
rejected  so  as  to  create  the  impression  that  the  child  is 
suffering  from  hsematemesis. 

"V\lien  the  nipple  first  begms  to  be  painful  absolute  alcohol 
should  be  freely  painted  over  it  after  each  feeding  time,  the 
nipple  being  previously  carefully  cleansed  with  boric  acid 
lotion  and  dried.  In  mild  cases  fissures  can  be  successfully 
treated  as  follows  :  A  nipple-shield  of  glass  or  rubber  must 
be  used  for  suclding,  so  as  to  protect  the  nipple  from  the 
child's  mouth  ;  in  addition  to  the  usual  cleansing,  the  nipple 
should  be  painted  with  a  mild  antiseptic  such  as  boro- 
glyceride,  glycerine  and  carbolic  acid  1-20,  or  dilute  sul- 
phurous acid  ;    finally  it  should  be  covered  ^vith  wet  boric 


INFECTION  563 

lint.  Dry  dressings  are  unsuitable,  as  free  drainage  from 
the  fissure  must  be  ensured.  When  the  fissures  are  severe, 
suckling  from  the  affected  breast  should  be  stopped  for 
twenty-four  hours,  the  nipple  disinfected,  by  painting 
it  with  1-500  perchloride  lotion  touched  with  nitrate  of 
silver,  and  the  whole  breast  tightly  bandaged  to  arrest  the 
secretion.  The  unaffected  breast  will  probably  suffice  for 
the  child's  needs  for  this  period  ;  if  not,  the  bottle  may  be 
given  as  well  (see  p.  618).  In  intractable  cases  suckling  may 
have  to  be  given  up  altogether. 

As  a  rule  nursing  women  do  not  menstruate,  but  there 
are  frequent  exceptions.  Women  who  do  not  nurse  usually 
begin  to  menstruate  in  from  four  to  six  weeks  after  their 
confinement.  When  lactation  ceases  menstruation  usually 
returns  after  about  the  same  interval. 

Puerperal  Infection 

Under  the  term  '  puerperal  infection  '  is  included  a  series 
of  febrile  disorders  of  the  lying-in  period  due  to  the  active 
development  of  certain  pathogenic  bacteria,  which  enter  the 
body  through  wounds  of  the  genital  tract  ;  in  the  great 
majority  of  cases  these  organisms  are  introduced  from  with- 
out, but  in  a  few  instances  they  may  have  been  present  in  the 
genital  tract  at  the  time  of  labour.  It  must  be  borne  in  mind 
that  puerperal  infection  may  occur  after  abortion  as  well  as 
after  labour. 

All  controversy  as  to  the  nature  of  '  puerperal  fever,' 
'  child-bed  fever,'  or  '  milk  fever  '  has  long  since  been  set 
at  rest,  and  we  now  know  it  to  be  due  to  sepsis  or  wound- 
infection.  To  a  Scotch  physician,  Robert  Gordon,  of  Aber- 
deen, belongs  the  credit  of  first  publicly  declaring  his  belief 
that  puerperal  fever  was  infectious  and  could  be  carried  from 
patient  to  patient  by  the  doctor  or  the  nurse  (1795).  About 
1840  to  1843  Oliver  WendeU  Holmes  in  the  United  States, 
and  Semmelweiss  in  Vienna,  independently  recognised  that 
puerperal  fever  could  also  be  set  up  by  infection  carried  from 
the  dead-house.  To  Semmelweiss  has  been  now  adjudged 
the  chief  credit  of  this  important  discovery  ;  but  his  work 
was  to  a  great  extent  neglected  for  thirty  years,  when  the 
discoveries  of  Lister  placed  the  matter  upon  a  scientific  basis 

36—2 


564  THE   PUERPERIUM 

by  showing  that  bacteria  were  the  agents  by  which  surgical 
infection  was  produced  and  propagated.  Doleris,  working 
with  Pasteur,  first  showed  in  1880  that  streptococci  could  be 
found  in  the  uterus  in  cases  of  '  puerperal  fever,'  thus 
definitely  bringing  the  disease  into  the  class  of  '  wound- 
infections,'  and  demonstrating  its  close  relation  to  suppura- 
tive processes.  Experience  has  shown  that  infection  from 
these  latter  sources  is  even  more  serious  than  infection  from 
the  cadaver. 

The  combined  work  of  these  observers  has  resulted  in  the 
practical  disappearance  of  puerperal  infection  from  lying-in 
hospitals,  and  has  undoubtedly  been  the  means  of  saving  the 
lives  of  innumerable  lying-in  women.  In  the  time  of  Sem- 
melweiss  outbreaks  of  puerperal  infection  occurred  from  time 
to  time  in  maternity  hospitals,  sometimes  attended  by  the 
appalling  mortality  of  60  to  75  per  cent.  ;  and  seldom  did  the 
mortality  from  puerperal  fever  in  these  institutions  fall  below 
10  per  cent.  At  the  present  time  the  mortality  from  puer- 
peral fever  in  such  hospitals  is  about  1  to  2  per  1,000,  and 
epidemics  are  unknown.  No  more  striking  instance  than 
this  exists  of  the  value  of  Lister's  principles.  But  puerperal 
infection  still  occurs,  although  not  in  epidemic  form,  and  the 
returns  of  the  Registrar-General  show  that  between  1893  and 
1 903  the  number  of  deaths  from  this  cause  in  England  and 
Wales  averaged  nearly  2,000  per  annum.  Boxall  showed 
that  during  this  period  of  ten  years  there  was  no  general 
improvement  in  the  mortality  from  puerperal  infection, 
although  it  must  be  assumed  that  the  medical  profession  has 
become  thoroughly  convinced  of  the  importance  of  the 
routine  application  of  antiseptic  principles  to  obstetric  work. 
A.  Causation. — There  are  three  factors  to  be  considered 
in  the  causation  of  puerperal  infection  :  (I.)  The  bacteria. 
(II.)  The  channels  of  infection.  (III.)  The  powers  of 
resistance  of  the  infected  tissues. 

I.  The  Bacteria.- — Since  puerperal  infection  gives  rise  to 
a  whole  group  of  disorders,  it  is  not  surprising  to  find  a 
variety  of  different  micro-organisms  concerned  in  its 
causation.  These  may  be  conveniently  divided  into  three 
groups  :  (a)  ancerobic  putrefactive  {saprophytic)  organisms  ; 
(b)  pyogenic  organisms  ;  (c)  certain  specific  organisms. 
(a)  Saprophytic  organisms  are  bacteria  which  grow  and 


INFECTION  565 

multiply  in  dead  tissues,  causing  the  phenomena  of  putrefac- 
tion ;  they  do  not  invade  the  body  generally,  and  they 
tend  to  disappear  spontaneously  when  the  pabulum  upon 
which  they  flourish  is  exhausted  ;  the  general  effects  which 
they  produce  are  due  to  the  absorption  into  the  circulation 
of  the  noxious  products  of  their  growth  and  development — 
the  toxins.  These  organisms  are  mostly  bacilli,  but  their 
varieties  are  very  numerous  and  do  not  require  full  men- 
tion. The  following  species  have  been  found  in  cases  of 
puerperal  infection  : 

(1)  Bacillus  proteus  vulgaris. 

(2)  Bacillus  septicus. 

(3)  Bacillus  aerogenes  capsulatus. 

They  are  the  chief  agents  in  the  production  of  the  clinical 
condition  to  be  described  later  on  as  uterine  saprcemia. 

(b)  Pyogenic  Organisms. — These  are  the  common  or- 
ganisms which  produce  suppuration  and  sepsis  ;  those  which 
have  been  found  in  connection  with  puerperal  infection  are  : 

(1)  Streptococcus  pyogenes. 

(2)  Staphylococcus  pyogenes. 

(3)  Bacillus  coli  communis. 

(4)  Bacillus  pyocyaneus. 

These  organisms,  no  matter  what  may  be  the  part 
of  the  body  first  attacked  by  them,  tend  to  spread  by  the 
lymphatics  and  blood-vessels  so  as  to  cause  general  septi- 
caemia. They  are  the  organisms  which  are  most  to  be  feared 
by  the  obstetrician,  for  their  distribution  in  crowded  centres 
of  population  is  almost  universal,  in  dust,  in  soiled  clothing, 
and  even  in  the  atmosphere.  The  discharges  from  a  case 
of  puerperal  fever  usually  contain  a  virulent  strain  of  or- 
ganisms of  this  group.  Every  focus  of  suppuration  forms  a 
centre  of  distribution  from  which  they  may  be  spread  broad- 
cast in  countless  numbers,  and  thus  become  the  cause  of  fresh 
wound-infection.  It  is  obvious  that  the  presence  of  suppu- 
rating sores  upon  the  hands  or  arms  of  the  medical  attendant 
or  nurse,  or  even  upon  the  body  of  the  patient,  must  involve 
the  most  serious  risk  of  infection  by  direct  contact.  And, 
further,  the  transmission  to  a  lying-in  woman  of  organisms 
from  other  patients  suffering  from  these  conditions  can  only 
be  avoided  by  the  most  scrupulous  surgical  cleanliness. 


566  THE   PUERPERIUM 

By  far  the  most  important  member  of  this  group  is  the 
streptococcus,  which  is  present  in  pure  culture  in  40  to  50  per 
cent,  of  cases  of  uterine  infection  (Lea).  In  a  series  of 
ninety-six  cases  Western  found  streptococci  in  80  per 
cent.,  and  of  these  76  per  cent,  were  pure  cultures.  Many 
different  varieties  of  streptococcus  are  known,  and  that 
concerned  in  puerperal  sepsis  does  not  appear  to  be  a 
specific  variety,  although  some  attempts  have  been  made 
to  show  that  it  possesses  specific  cultural  reactions.  In 
addition  it  is  frequently  present  in  association  with  other 
organisms,  one  of  the  most  frequent  associates  being  the 
bacillus  coli.  The  most  severe  of  all  cases  of  puerperal 
fever  are  due  to  these  two  organisms,  either  alone  or  in 
company  with  one  another.  Streptococci  occur  in  a  variety 
of  different  degrees  of  virulence,  and  there  are  many  varying 
types.  Some  are  saprophytic  only,  or  even  apparently 
non-pathogenic,  and  it  has  been  mentioned  that  such 
organisms  may  occur  in  the  discharges  of  healthy  lying-in 
women.  Organisms  belonging  to  the  same  classes  may  be 
found  in  the  skin  of  the  vulva  and  in  the  vaginal  secretions 
of  pregnant  and  non-pregnant  women,  and  also  in  the 
lochial  discharges  in  normal  cases. 

(c)  Specific  Organisms. — The  following  specific  organisms 
have  been  found  in  cases  of  puerperal  infection  : 

(1)  Diplococcus  gonorrhcese. 

(2)  Bacillus  diphtherise  (Klebs-Loffler). 

(3)  Pneumococcus. 

(4)  Bacillus  tetani. 

(5)  Bacillus  typhosus. 

The  actual  relation  of  these  latter  organisms  to  the 
causation  of  puerperal  infection  is  a  matter  of  some  uncer- 
tainty. There  is  reason  to  believe  that  the  two  first- 
named  may  in  certain  cases  be  the  sole,  or  at  any  rate  the 
principal,  cause  of  infection.  The  three  last-named  pro- 
bably occur  only  in  association  with  the  pyogenic  cocci, 
although  this  is  denied  by  some  authorities.  The  gono- 
coccus  produces  as  a  rule  only  local  pelvic  inflammation  ; 
both  the  pneumococcus  and  the  bacillus  coli  may  produce 
virulent  forms  of  peritonitis  or  general  septicaemia.  The 
Klebs-Loffler  bacillus  produces  in  the  genital  tract  the  same 


INFECTION  567 

species  of  false  membrane  which  characterises  throat- 
infection  by  the  same  organism.  Puerperal  tetanus  occurs, 
but  is  an  extremely  rare  condition. 

Mixed  Infection. — Puerperal  infection  is  not  always  due 
to  a  single  species  of  organism  ;  and,  further,  in  a  large 
number  of  cases  it  cannot  even  be  said  that  the  organisms 
concerned  belong  to  a  single  member  of  the  three  great 
groups  just  described.  Saprophytes  may  be  found  in  com- 
pany with  pyogenic  cocci,  and  the  latter  with  certain  of  the 
specific  organisms  ;  or  members  of  all  three  groups  may  be 
associated  in  a  single  case.  This  fact,  as  we  shall  see,  exerts 
an  important  influence  upon  the  clinical  features  and  treat- 
ment of  cases  of  puerperal  infection.  It  is  believed  that  the 
most  virulent  cases  are  those  due  to  mixed  infection.  It  also 
appears  that  the  pyogenic  cocci  may  sometimes  assume  a 
saprophytic  role,  remaining  confined  to  the  uterine  cavity, 
and  producing  symptoms  of  saprsemia  alone. 

Autogenetic  and  Heterogenetic  Infection. — In  almost  every 
case  of  puerperal  infection  the  organisms  are  introduced  into 
the  genital  tract  from  without  {heterogenetic  infection),  by 
surgically  unclean  fingers,  instruments,  diapers,  or  other 
matters  applied  to  or  introduced  within  the  vulva.  It  must 
not  be  forgotten  that  the  vulva  itself,  like  all  other  areas  of 
skin,  usually  contains  numerous  organisms,  and  that  hands 
or  instruments,  after  being  carefully  sterilised,  may  become 
re-infected  in  passing  through  it.  The  risk  of  hetero-infection 
will  be  greatly  increased  by  the  presence  of  local  sores,  such 
as  fistula  in  ano,  vulval  furuncles,  etc.,  or  of  sores  upon  the 
hands  of  the  medical  attendant  or  nurse,  or  by  contact  with 
other  sources  of  infection,  or  by  insanitary  personal  or 
general  surroundings.  But  of  all  modes  of  infection,  the  one 
most  to  be  feared  is  the  carriage  of  organisms  from  one  case 
of  puerperal  infection  to  another.  Puerperal  infection  by 
the  bacillus  coli  is  not  necessarily  autogenetic — i.e.,  the 
organisms  may  be  derived  from  external  sources,  not  from 
the  intestinal  tract  of  the  patient.  So  far  as  we  know,  this 
bacillus  only  becomes  virulent  to  its  host  in  certain  morbid 
conditions  (injury  or  disease)  of  the  bowel.  But  it  occurs 
widely  distributed  in  dust,  especially  road  dust,  and  may 
therefore  be  introduced  into  the  genital  canal  as  the  result  of 
imperfect  surgical  cleanliness.     Sewer  gas  was  at  one  time 


568  THE    PUERPERIOI 

regarded  as  a  potent  cause  of  puerperal  infection  ;   this  was 
probably  an  error,  for  sewer  gas  contains,   as  a  rule,  no 
bacteria,,  and  the    effects  it  produces    upon    the    lying-in 
woman  are  those  of  sewer-gas  poisoning,  not  wound-infection. 
By  autogenetic  infection  is  meant  infection  of  the  genital 
tract  by  organisms  existing  in  or  near  it  before  labour.     The 
possibilities  of  auto-iniection  are.  however,  strictly  hmited, 
and  this  variety  shoidd  never  be  diagnosed  in  a  particular 
case  without  the  clearest  demonstration.     It  cannot  be  said 
that  amiihmg  hke  satisfactory  evidence  of  auto-infection  has 
ever  been  furnished  in  the  case  of  any  organism  except  the 
gonococcus.     Puerperal  infection  may,  however,  be  caused 
by  gonococci  which,  during  pregnancy,  have  been  lurking  in 
some  part  of  the  vagma  or  cervix,  or  even  in  the  decidua  or 
the  Eallopian  tube.     The  possibility  of  this  organism  remain- 
ing latent  for  a  considerable  time,  and  then  assuming  well- 
marked  activity  on  being  transferred  to  a  new  location,  is 
well   known,   and   doubtless   accounts  for  its   occasionally 
causing  serious  results  in  h^ng-hi  women.     In  this  way  acute 
ascending  gonorrhoeal  inflammation  may  arise,  involving  not 
only  the  uterine  cavity,  but  also  the  ovaries,  tubes,  and 
peritoneum.     Again,  when  such  local  conditions  are  present 
as  carcinoma  of  the  cervix,  appendicitis,  cystitis,  or  pelvic 
abscess,  acute  infection  of  the  genital  tract  from  these  sources 
may  also  occur  spontaneously.     But  when  puerperal  sepsis 
accompanies  acute  specific  fevers  such  as  scarlatina,  typhoid, 
or  diphtheria,  it  is  much  more  probable  that  the  infection  has 
been  carried  from  without  than  that  it  has  reached  the 
genital  canal  through  the  circulation,  although  it  cannot  be 
denied  that  this  is  theoretically  possible. 

It  must  not  be  forgotten,  however,  that  bacteria  are 
found  in  normal  conditions  in  the  lower  part  of  the  genital 
tract.  Such  organisms  are  probably"  non- virulent  and 
incapable  of  producmg  an  acute  general  infection  ;  they 
may,  however,  be  the  cause  of  the  milder  forms  of  local 
infection  described  below. 

II.  The  Channels  of  Infection. — (a)  Lochia. — The  normal 
defence  against  infection  offered  hj  the  healthy  vaginal 
secretion  with  its  specific  bacillus  is  lost,  and  the  alkaline 
lochia,  rich  in  albuminous  material,  provide  an  excellent 
culture-medium    for    any    organisms    which    may    obtain 


INFECTION  569 

access  to  them.  The  condition  of  the  genital  tract  is, 
accordingly,  such  as  to  offer  special  facilities  for  bacterial 
infection. 

(b)  Dead  Tissue. — A  certain  amount  of  dead  tissue  is 
always  present  in  the  puerperal  uterus — viz.,  fibrin,  blood- 
clot,  and  a  thin  layer  of  decidua  which  undergoes  necrosis 
and  is  cast  off.  This  may  be  supplemented  by  fragments 
of  placental  tissue  or  chorionic  membrane  which  remain 
attached  to  the  uterine  wall.  Thus  the  conditions  requisite 
for  the  growth  of  saprophytic  organisms  always  exist  in 
greater  or  less  degree  in  the  puerperal  uterus.  In  difficult  or 
instrumental  labour,  areas  of  sloughing  from  prolonged  or 
excessive  compression  may  also  occur. 

(c)  Wounds. — After  every  normal  labour  the  continuity 
of  the  surface  of  the  genital  tract  is  broken  by  separation  of 
the  placenta,  and  by  the  more  or  less  considerable  lacerations 
which  usually  occur  in  the  cervix  or  near  the  vulva  ;  the 
•latter  are  more  severe  and  of  more  frequent  occurrence  in 
primiparee  than  in  multiparse.  Through  these  wounds  toxins 
may  be  absorbed  into  the  circulation,  or  pyogenic  organisms, 
if  present,  may  invade  the  tissues  of  the  body  generally. 
When  introduced  into  wounds  of  the  cervix  and  vaginal  roof, 
organisms  will  find,  in  the  lymphatic  channels,  a  reSdy  way 
of  access  to  the  cellular  tissue  of  the  broad  ligament,  and  may 
thus  give  rise  to  pelvic  cellulitis.  It  is  probable,  from  what 
is  known  of  the  pathological  anatomy  of  puerperal  sepsis, 
that  generalised  infection  usually  occurs  by  extension  from 
an  infected  uterus,  and  not  by  absorption  from  wounds  of 
the  cervix  or  vagina.  Bacteriological  evidence  has,  however, 
been  adduced  by  Foulerton  and  Bonney  which  appears  to 
indicate  that  mild  cases  of  puerperal  fever  may  be  due  to 
infection  through  lacerations  of  the  lower  part  of  the  genital 
tract,  the  uterus  remaining  uninfected  and  its  contents 
sterile.  But  severe  cases  of  puerperal  fever  are  probably  in 
all  instances  the  result  of  uterine  infection. 

III.  The  Powers  of  Resistance. — The  effects  produced  by 
bacterial  infection  depend  partly  upon  the  number  and 
degree  of  virulence  of  the  organisms,  and  partly  upon  the 
resistance  offered  by  the  tissues  to  their  development.  The 
general  resistances  are  reduced  by  anything  which  exhausts 
or  debilitates  the  patient  such  as  previous  ill-health,  pro- 


570 


THE  PUERPERIUM 


longed  or  difficult  labour,  haemorrhage  during  or  after  labour, 
albuminuria,  pre-existing  pelvic  inflammation,  etc.     Under 


Smooth  uterine  wall 


Fig.  269. — Uterus  from  a  Case  of  Placenta  Prsevialiand  Puerperal 
Septicsemia  ;  Streptococcic  Infection  ;  Death  on  Fourth  Day. 

It  will  be  noticed  that  the  thrombosed  placental  sinuses  are  in  the  lower  uterine  segment. 

such  conditions  the  normal  means  of  defence  against  bacterial 
invasion  are  inhibited  or  impeded,  and  no  effective  opposi- 


INFECTION  571 

tion  can  then  be  offered  by  the  tissues  to  the  attack  of  the 
organisms.  In  addition  it  must  be  borne  in  mind  that  the 
risks  of  infection  may  be  increased  by  the  character  of  the 
labour,  and  especially  by  such  conditions  as  premature 
rupture  of  the  membranes,  or  prolonged  labour,  and  such 
operative  procedures  as  induction  of  labour,  forceps,  version, 
etc.  The  conditions  just  named  are  accordingly  often  spoken 
of  as  predisposing  causes  of  infection, 

B.  Pathological  Anatomy  of  Puerperal  Infection. — Cases 
of  extreme  virulence,  which  rapidly  reach  a  fatal  termination 
in  from  two  to  three  days,  are  sometimes  met  with,  in  which 
practically  no  morbid  changes  can  be  found  in  the  genital 
tract.  These  cases  are  usually  due  to  streptococcic  infection, 
the  organisms  directly  entering  the  blood  and  lymph  vessels, 
and  producing  practically  no  reaction  at  the  points  of  entry. 
Death  is  due  to  an  overwhelmingly  rapid  formation  of  toxins 
within  the  circulation.  In  the  majority  of  cases  of  puerperal 
infection,  however,  well-marked  alterations  are  found  in  the 
genital  tract,  but  they  differ  greatly  in  their  nature  and 
distribution. 

(1)  The  Uterus. — -The  general  condition  of  the  wall  of  the 
uterine  cavity  is  variable.  In  pure  streptococcic  infection  it 
is  believed  to  be  usually  smooth  and  uniform,  with  little 
evidence  of  superficial  necrosis.  Thus  in  Fig.  269  the  greater 
part  of  the  wall  is  smooth,  but  the  placental  site  presents  the 
usual  elevated  and  irregular  appearance .  In  mixed  infection, 
on  the  other  hand,  the  wall  is  shaggy  and  irregular  from  the 
presence  of  necrotic  tissue. 

The  condition  of  the  uterine  wall  is,  in  general  terms, 
similar  to  that  of  an  infected  wound  in  any  other  part  of  the 
body  ;  but  the  local  appearances  depend  to  a  great  extent 
upon  the  type  of  organisms  present.  It  is  generally  agreed 
that  two  varieties  may  be  distinguished,  named  putrid  (sapro- 
phytic) and  infective  (septic)  endometritis. 

Putrid  Puerperal  Endometritis. — In  this  condition  the 
uterus  is  large  and  flabby,  and  usually  contains  adherent 
fragments  of  membranes,  placenta  or  blood-clot,  and  fre- 
quently, but  not  always,  an  offensive  odour  is  noticeable. 
There  may  be  a  thick  layer  of  decidua  or  polypoid  masses 
may  be  found  on  the  placental  site  ;  sometimes  bubbles  of 
gas  are  visible  in  the  decomposing  tissues.     This  form  is 


572 


THE   PUERPERIUM 


mainly  due  to  infection  by  mixed  putrefactive  bacteria,  but 
the  streptococcus  and  bacillus  coli  are  also  not  infrequently 
present.  On  microscopic  examination  of  the  uterine  wall, 
a  well-marked  zone  of  leucocytic  infiltration  is  found  beneath 
the  necrotic  laj'er  ;  this  zone  appears  to  form  a  barrier  to  the 
advance  of  the  infecting  organisms,  for  none  are  found  either 
in  it  or  in  the  tissues  Ijdng  beneath  it  (Fig.  270).  Accordingly, 


Fig.  270. — Puerperal  Endoraetritis,   showing  mai'ked  development 
of  the  Leucocytic  Zone.     (Whitridge  Williams.) 

a.  Fibrin  layer,     h.  Leucocytic  zone.     c.  Muscular  wall  with  vessels. 

with  this  variety  of  puerperal  endometritis,  symptoms  of 
general  infection  are  absent,  for  the  dissemination  of  the 
organisms  is  prevented. 

Infective  Puerperal  Endometritis.  —  In  this  form  the 
uterus  is  small,  the  cavity  lined  with  a  greyish  layer  of 
exudation,  there  are  no  retained  tissues  to  be  seen,  there  are 
no  bubbles  of  gas,  and  no  foetor.  It  is  caused  by  the  group 
of  p3^ogenic  cocci,  of  which  the  streptococcus  is  the  most 
frequent,  being  found  either  alone  or  in  association  in  60  to 


INFECTION  573 

70  per  cent,  of  cases  (Lea).  This  variety  may,  however,  also 
be  due  to  the  bacillus  coli  or  the  gonococcus.  On  micro- 
scopic examination  it  is  found  that  the  zone  of  leucocytic 
infiltration,  although  present,  is  less  extensive  than  in  the 
first-named  variety,  and  numerous  organisms  will  be  found 
to  have  invaded  it — i.e.,  the  barrier  to  dissemination  of  the 
organisms  is  feeble.  In  some  cases  the  leucocytic  zone  is  not 
continuous,  presenting  gaps  here  and  there,  through  which 
the  organisms  can  be  seen  to  have  made  their  way  freely  into 
the  lymphatic  spaces  and  blood-vessels  of  the  subjacent 
muscle.  In  this  way  the  frequency  with  which  streptococcic 
uterine  infection  is  accompanied  by  symptoms  of  general 
septicsemia  can  be  anatomically  explained.  Occasionally, 
when  the  leucocytic  zone  is  complete,  streptococcic  endo- 
metritis may  produce  only  symptoms  of  localised  uterine 
infection  (sapraemia). 

In  cases  of  mixed  infection  by  saprophytic  and  pyogenic 
organisms,  atypical  appearances  will  be  presented  in  the 
uterus.  Adherent  fragments  of  placenta  or  chorion  may  be 
found  in  either  variety  of  puerperal  endometritis. 

The  muscular  wall  of  the  uterus  also  is  usually  more  or 
less  inflamed  (metritis)  in  both  forms  of  puerperal  endo- 
metritis. In  rare  instances  of  the  septic  variety  multiple 
small  interstitial  abscesses  may  form.  In  very  rare  instances 
sloughing  of  more  or  less  extensive  areas  of  the  muscular 
wall  occurs — the  so-called  metritis  desiccans.  The  venous 
channels  in  the  general  uterine  wall  are  frequently  found 
thrombosed  and  inflamed  (phlebitis),  and  small  collections 
of  pus  may  sometimes  be  found  in  the  thrombi,  and  outside 
the  vessel  walls  in  the  tissues  around  them.  The  general 
muscular  tissue  is  said  to  be  unusually  soft  and  friable,  and 
specially  liable  to  perforation  by  such  instruments  as  the 
curette. 

The  serous  coat  may  escape  altogether,  or  in  cases  of  great 
severity,  patches,  or  a  complete  coating,  of  lymph  may  form 
upon  it  ;  in  such  cases  the  whole  of  the  pelvic  peritoneum, 
along  with  the  tubes  and  ovaries,  is  generally  inflamed 
(perimetritis,  pelvic  peritonitis).  Infection  of  the  peritoneal 
coat  may  be  brought  about  by  extension  from  the  infected 
uterine  cavity  through  the  lymphatics,  or  through  the 
advance   of   the   infection   by   direct   continuity   from   the 


574  THE   PUERPERIUM 

uterine  cavity  to  the  mucous  membrane  of  the  Fallopian 
tubes,  and  through  the  abdominal  ostia  to  the  pelvic  peri- 
toneum. 

(2)  The  Cervix,  Vagiyia,  and  Vulva. — Lacerations  of  these 
parts,  when  infected,  assume  the  appearance  of  ulcers  with 
a  dirty  greyish  base,  produced  by  the  formation  of  a  false 
membrane  consisting  of  the  superficial  necrosed  tissues.  In 
cases  of  severe  perineal  lacerations  which  have  become 
infected,  superficial  sloughing  may  occur  over  large  areas  of 
the  injured  tissues.  Sometimes  areas  of  sloughing  are  met 
with  in  the  anterior  vaginal  wall.  They  are  produced  by 
prolonged  and  severe  compression  of  the  part  between  the 
foetal  head  and  the  pubes,  or  between  the  forceps  and  the 
pubes  ;  they  are  accordingly  most  often  met  with  after  a 
long  and  difficult  second  stage.  If  the  patient  survives,  such 
sloughs  separate  during  the  first  seven  to  ten  days  of  the 
puerperium,  and  usually  they  produce  a  vesico-vaginal 
fistula,  since  the  base  of  the  bladder  is  necessarily  involved 
in  the  compression  and  sloughing. 

(3)  Pelvic  Cellular  Tissue. — Large  inflammatory  effusions 
{cellulitis)  may  be  met  with  in  one  or  both  broad  Hgaments  ; 
or  they  may  be  so  extensive  as  to  involve  the  whole  of  the 
pelvic  cellular  tissue  and  spread  to  that  of  the  iliac  fossa  and 
anterior  abdominal  wall.  Such  an  effusion  between  the 
layers  of  the  broad  Hgament  is  often  called  a  broad-ligament 
'phlegmon.  The  cellular  tissue  usually  becomes  infected  by 
lymphatic  extension  from  wounds  of  the  cervix  ;  cellulitis  is 
probably  always  accompanied  by  a  certain  amount  of  uterine 
infection,  but  clinically  the  condition  of  the  cellular  tissue 
obscures  that  of  the  uterus,  and  the  case  is  regarded  mainly, 
if  not  entirely,  as  one  of  cellulitis.  On  post-mortem  examina- 
tion a  recent  cellulitic  effusion  forms  a  spongy  mass,  from 
which  a  clear  or  slightly  tui'bid  fluid  exudes  on  section. 

(4)  Peritoneum,  Fallopian  Tubes,  and  Ovaries. — Peri- 
tonitis of  variable  extent  is  usually  found  in  fatal  cases  of 
jDuerperal  fever.  A  certain  amount  of  pelvic  peritonitis  often 
accompanies  severe  cases  of  uterine  infection  which  recover, 
and  if  limited  to  the  pelvic  cavity  it  is  not  necessarily  fatal. 
Occasionally  acute  general  peritonitis  may  be  set  up  by 
an  infected  uterus.  The  infection  may  occur  by  direct 
lymphatic  spread,  but  sometimes  may  arise  from  lacerations 


INFECTION  575 

of  the  uterus  or  vagina,  through  which  direct  infection  may 
occur  ;  this  is  often  seen  in  rupture  of  the  uterus,  or  after 
perforation  of  the  uterus  from  induction  of  abortion  by 
unskilled  persons  (criminal  abortion).  The  Fallopian  tubes 
may  become  infected  by  direct  spread  from  the  uterine 
cavity,  and  from  them  the  infection  spreads  to  the  ovaries 
and  the  pelvic  peritoneum.  Pyosalpinx  and  ovarian  abscess 
sometimes  form,  either  rapidly  or  after  a  considerable 
interval.  These,  however,  occur  more  frequently  with 
gonorrhoeal  than  with  other  forms  of  infection. 

(5)  Pelvic  Veins.-^The  thrombosed  vessels  beneath  the 
placental  site  frequently  become  infected  by  organisms  which 
penetrate  the  blood-clot.  Thence  they  spread  in  the  sub- 
endothelial  connective-tissue  along  the  walls  of  the  vessels — 
chiefly  the  veins,  setting  up  a  spreading  phlebitis.  Phlebitis 
may  spread  from  the  infected  uterus  into  the  broad  liga- 
ments ;  thence  it  may  pass  upwards  through  the  ovarian 
veins  to  the  renal  veins,  and  through  the  iliac  veins  to  the 
inferior  vena  cava,  and  the  resulting  long  line  of  blood- 
clot  may  even  reach  the  right  ventricle.  In  other  cases  it 
passes  downwards  into  the  femoral  vein,  causing  femoral 
thrombosis — a  variety  of  the  condition  clinically  known  as 
phlegmasia  alba  dolens  (see  p.  598). 

Septic  phlebitis  is  probably  to  be  regarded  as  a  defensive 
reaction  against  the  spread  of  the  infection  ;  as  has  been 
mentioned,  the  most  virulent  infections  do  not  show  it  at  all. 
Following  upon  the  phlebitis,  coagulation  of  blood  occurs, 
and  the  affected  vessel  thus  becomes  partially  or  wholly 
blocked  (thrombosis).  The  clot  thus  formed  is  infective, 
and  in  many  cases  minute  particles  become  detached  as 
emboli,  and  being  carried  to  distant  parts  by  the  blood  stream 
the  condition  known  as  pycemia  results.  Such  cases, 
although  severe,  nearly  always  run  a  prolonged  clinical 
course. 

C.    Clinical  Varieties  of  Puerperal  Infection 

The  following  clinical  varieties  of  puerperal  infection 
must  be  considered  : 

^    T-T.     •      •  i-    ^-        (Saprsemia, 
1.  Uterme  infection   i^     x- 

Septicaemia. 


576  THE   PUERPERIUM 

2.  General  puerperal  peritonitis. 

3.  Local  pelvic  inflammation  : 

Cellulitis. 
Peritonitis. 
Salpingo-oophoritis. 
Thrombo-phlebitis. 

4.  Phlegmasia  alba  dolens. 

5.  Pysemia. 

1.  Uterine  Infection. — From  what  has  been  already  said 
in  connection  with  the  pathological  anatomy  of  puerperal 
infection,  it  will  be  evident  that  cases  of  infection  of  the 
uterus  may  be  divided  into  two  classes,  corresponding  to  the 
two  varieties — ^putrid  and  septic — of  puerperal  endometritis. 
Upon  this  basis  two  clinical  types  may  be  distinguished 
— saprcemia,  corresponding  to  putrid  endometritis,  and 
septiccemia,  corresponding  to  septic  endometritis.  Saprcemia 
may  accordingly  be  described  as  a  local  uterine  infection,  due 
in  the  great  majority  of  instances  to  saprophytic  bacteria, 
but  sometimes  to  pyogenic  organisms  ;  there  is  no  general 
dissemination  of  the  organisms,  which  are  limited  to  the 
uterine  cavity,  and  the  clinical  symptoms  are  produced  by 
the  absorption  from  the  uterus  of  the  toxic  products  of 
bacterial  action.  It  is  therefore  a  septic  toxaemia.  Septi- 
ccemia may  be  described  as  a  generahsed  infection  due  to 
pyogenic  cocci,  to  the  bacterium  coli,  or  to  various  specific 
organisms,  which  enter  the  body  through  the  genital  tract, 
and  become  widely  disseminated  through  the  lymphatic  or 
vascular  system.  Technically  the  diagnosis  of  septicaemia 
is  made  by  recognising  the  infecting  organism  in  the  blood 
stream.  In  fact,  their  presence  in  the  blood  stream  is  not 
constant ;  they  appear  to  pass  into  the  blood  from  the 
infection-site  intermittently  and  in  comparatively  small 
numbers,  and  they  do  not  long  remain  there  except  in  the 
case  of  infective  emboli.  In  many  cases  of  undoubted 
septicaemia  blood  cultures  are  negative,  and  Western  only 
succeeded  in  getting  a  positive  result  in  40  per  cent,  of  100 
cases  examined.  The  best  time  to  obtain  blood  for  culture 
is  probably  immediately  after  a  rigor  or  when  the  tempera- 
ture is  at  its  highest.  The  passage  of  organisms  from  the 
uterus  into  the  blood  stream  is  due  to  an  imperfect  defensive 


INFECTION  577 

barrier,  and  this  affords  an  easy  explanation  of  the  '  border- 
Hne  '  cases  in  which  a  differential  diagnosis  between 
sapraemia  and  septicaemia  may  be  very  difficult. 

It  will  be  remembered,  however,  that  the  occurrence  of 
mixed  infection  is  not  infrequent,  and  in  such  cases  the 
local  appearances  in  the  uterus  are  atypical,  and  cannot 
be  definitely  placed  in  either  class  ;  so  also  in  such  cases 
the  clinical  features  are  irregular,  and  may  comprise 
many  of  those  of  both  classes.  While,  therefore,  it  may 
be  easy  to  make  a  diagnosis  of  uterine  infection,  it  is  not 
always  possible  to  carry  the  diagnosis  further  than  this, 
and  the  names  '  sapraemia  '  and  '  septicaemia  '  must  accord- 
ingly be  applied  with  some  caution.  In  general  terms  it 
may  be  said  that  sapraemic  infection  is  less  severe  than 
septicaemic  infection  ;  the  resulting  illness  accordingly  is 
milder,  runs  a  shorter  course,  and  is  less  likely  to  be  attended 
by  complications. 

The  Onset  of  Uterine  Infection. — It  is  in  the  initial  stage 
that  the  differential  diagnosis  of  the  two  varieties  is  difficult, 
and  it  will  be  best  in  the  first  place  to  consider  the  general 
symptoms  of  the  onset  of  uterine  infection  without  reference 
to  its  subdivisions. 

The  occurrence  of  evanescent  rises  of  temperature  in 
the  puerperium  from  trivial  causes  has  been  already  referred 
to  ;  it  will  be  remembered  that  in  such  cases  the  pyrexia  is 
moderate  in  degree,  is  of  brief  duration,  and  yields  easily 
to  treatment.  The  possibility  of  the  occurrence  of  inter- 
current febrile  affections,  unconnected  with  the  puerperal 
state,  is  also  to  be  borne  in  mind.  But  the  general  rule  which 
must  be  rigidly  applied,  is  that  every  case  of  '  fever  ' 
arising  in  the  puerperium  should  be  regarded  as  the  result 
of  infection  unless  some  other  cause  for  it  can  be  definitely 
recognised. 

The  onset  of  uterine  infection  almost  always  occurs  in  the 
first  puerperal  week,  and,  except  in  rare  instances,  during  the 
first  four  to  five  days.  Cases  occurring  within  the  first  three 
days  are  probably  due  to  infection  during  labour  ;  cases 
beginning  later  than  this  are  probably  due  to  infection  sub- 
sequent to  labour.  In  mild  cases  the  onset  is  characterised 
by  rise  of  temperature  to  101°  to  102°  F.,  corresponding,  or 
sometimes  exaggerated,  rapidity  of  the  pulse,  frontal  head- 
E.M.  37 


578  THE   PUERPERIUM 

ache,  and  more  or  less  feeling  of  general  illness  or  malaise. 
In  severe  cases  the  rise  of  temperature  is  ushered  in  or  quickly 
followed  by  a  rigor,  the  frequency  of  the  pulse  is  exaggerated, 
the  headache  and  malaise  are  more  pronounced,  and  some- 
times vomiting  occurs.  Sapreemia  is  much  more  frequently 
associated  with  the  mild  type  of  onset  than  with  the  severe 
type  ;  septicaemia  may  be  equally  well  associated  with  either. 
Accordingly,  while  the  mild  type  of  onset  is  of  no  value  in 
differential  diagnosis,  the  severe  type  of  onset  indicates  the 
probability  of  the  case  being  one  of  septicaemia.  A  case 
which  begins  mildly  may,  however,  run  a  severe  and  pro- 
longed course. 

The  condition  of  the  uterus  must  be  carefully  observed  at 
the  onset  of  uterine  infection.  In  sapraemia  involution  is 
usually  delaj^ed  or  arrested  ;  in  addition,  the  uterine  cavity 
may  contain  infected  blood-clot  or  pieces  of  adherent  placenta 
or  membrane.  Consequently  the  uterus  is  abnormally  large 
for  the  puerperal  date,  and  also,  usually,  tender  to  the  touch. 
In  septicaemia,  on  the  other  hand,  involution  is  usually 
unaffected,  the  uterine  cavity  is  empty,  and  the  size  of  the 
uterus  corresponds  to  the  puerperal  date.  Many  atypical 
cases  will,  however,  be  met  with  in  which  septicaemia  is 
accompanied  by  sapraemia.  and  the  uterus  is  too  large  for  the 
puerperal  date. 

The  lochia  frequently  become  putrescent  (offensive)  in 
uterine  infection.  This  is  especially  likely  to  occur  if  the 
uterine  cavity  contains  blood-clot  or  placenta,  and  if  sapro- 
phytic organisms  obtain  access  to  it.  It  is  therefore  com- 
monly met  with  in  sapraemia.  But  the  presence  of  an 
offensive  discharge  must  not  be  regarded  as  indicating  any- 
thing further  than  infection  ;  it  does  not  even  follow, 
necessarily,  that  the  infection  is  in  the  uterus.  The  lochia 
may  decompose  at  the  vulva  or  in  the  vaginal  canal,  while 
the  uterus  remains  unaffected,  and  no  unfavourable  symp- 
toms whatever  occur.  On  the  other  hand,  septicaemia  of  the 
greatest  severity  may  occur  without  any  decomposition  of 
the  lochia  whatever. 

From  what  has  just  been  said,  it  will  be  clear  that  it  is 
often  impracticable  at  the  onset  of  a  case  of  uterine  infection 
to  distinguish  septicaemia  and  sapraemia  from  one  another. 
Time  is  required  in  order  that  the  general  course  of  the  iUness 


INFECTION 


579 


and  the  effects  of  local  treatment  may  be  observed.  But  the 
treatment  of  uterine  infection,  to  be  efficacious,  must  be 
applied  without  delay,  and  consequently  the  onset  of  the 
disease  must  often  be  treated  before  a  differential  diagnosis 
of  the  two  varieties  is  practicable.  Treatment  will  be 
described  later  on  ;  in  the  meantime  the  general  features  of 
simple  sapraemia  and  simple  septicaemia  may  be  described, 
it  being  continually  borne  in  mind  that  cases   of  mixed 


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Temperature  and  Arrest  of  Involution  on  the  Fourth,  Fifth  and 
Sixth  Days. 

infection  which  resemble  both,  and  differ  from  either,  are 
frequently  encountered. 

Sapraemia. — The  three  outstanding  clinical  features  of 
this  condition  are  pyrexia,  decomposition  of  the  lochia,  and 
arrest  of  the  process  of  involution  of  the  uterus. 

The  time  of  onset  varies  with  the  date  of  infection  ;  if 
infection  has  occurred  during  labour,  the  symptoms  usually 
appear  on  the  second  or  third  day  ;  if  infection  has  occurred 
subsequent  to  delivery,  the  symptoms  will  appear  later.  As 
a  rule,  the  first  symptom  to  appear  is  fever,  which  may  be 
slight  (100°  to  102°  F.)  as  in  Fig.  271,  or  severe  (102°  to 
104°  F.)  as  in  Fig.  272  ;  a  slight  shivering  may  accompany 
the  initial  rise,  but  a  pronounced  rigor  is  unusual.  The 
pulse-rate  rises  to  an  extent  proportionate  to  the  tempera- 

37—2 


580 


THE   PUERPERIUM 


ture.  A  certain  amount  of  headache  and  general  malaise  are 
present,  but  the  patient  does  not  appear  to  be  seriously  ill. 
On  examination  of  the  abdomen,  the  uterus  will  usually  be 
found  to  be  unduly  large  for  the  puerperal  date  ;  it  is  tender 
to  the  touch,  and  softer  than  normal  in  consistence.  The 
vulval  pads  should  always  be  examined,  when  the  foetor  of 
the  lochia,  if  present,  will  be  perceived,  and  shreds  of  tissue 
may  be  found  upon  them.  In  occasional  instances  no 
decomposition  of  the  iochia  can  be  detected  ;  these  cases  are 
probably  due  to  infection  by  pyogenic  cocci,  the  growth  of 


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Fig.  272. — Chart  of  a  more  Severe  Case  of  Saprsemia  whicli  lasted 
from  the  Second  to  the  Eighth  Day. 


which  has  been  limited  to  the  uterine  cavity.  The  amount 
of  the  lochia  is  often  profuse,  and  sometimes  an  admixture 
of  fresh  haemorrhage  may  be  observed.  A  mild  case  of 
saprsemia  when  suitably  treated  can  usually  be  cured  in  two 
or  three  days  ;  more  severe  cases  may  last  for  a  week 
or  upwards  before  yielding  to  treatment  (Fig.  272).  If 
untreated,  the  symptoms  may  increase  in  severity,  and 
generalised  infection — indicated  by  rigors  and  great  rapidity 
of  the  pulse — or  local  pelvic  lesions,  wiU  foUow — *.e.,  the  case 
has  become  one  of  septicaemia.  Very  slight  cases  of  saprsemia 
are  often  met  with  in  which  the  only  abnormal  indications 
are  slight  fever  (100°  to  101°  F.)  and  a  little  enlargement 


SEPTICiEMIA  581 

without  tenderness  of  the  uterus.  Or  a  similar  degree  of 
fever  may  be  the  result  of  infection  of  superficial  "tears  of  the 
vulva,  perineum,  or  vaginal  walls.  The  patient  may  appear 
to  be  perfectly  well ;  she  complains  of  no  headache,  and  the 
lochia  are  healthy.  It  is  possible  that  such  cases  are  some- 
times due  to  imperfect  uterine  drainage,  resulting  perhaps 
from  the  recumbent  position,  or  from  the  presence  of  an 
uninfected  clot  in  the  uterus,  preventing  the  free  escape  of 
the  lochia.  The  result  is  absorption  from  the  uterus  of  waste 
products  sufficient  slightly  to  raise  the  temperature. 

Septicaemia. — The  symptoms  of  septicaemia  bear  a  broad 
resemblance  to  those  of  saprsemia  just  described  ;  generally 
speaking,  however,  they  may  be  said  to  be  of  much  greater 
severity,  and  much  less  amenable  to  local  treatment.  Sep- 
ticaemia may  be  produced  not  only  by  various  organisms,  but 
by  various  classes  of  organisms  ;  the  clinical  features  accord- 
ingly show  great  variations.  And  further,  since  organisms 
exist  in  nature  in  various  degrees  of  attenuation,  the  severity 
of  the  symptoms  which  they  produce  is  variable.  An 
exhaustive  description  of  puerperal  septicaemia  is  accordingly 
impossible  except  in  a  monograph  ;  its  main  features  can, 
however,  be  briefly  presented.  Our  present  knowledge  does 
not  enable  us  to  recognise,  from  the  clinical  features,  the 
organisms  by  which  it  is  produced  in  a  particular  case. 

Onset. — The  onset  is  almost  always  acute,  and  seldom 
occurs  later  than  the  third  day  of  the  puerperium  ;  it  may, 
however,  occur  within  twenty-four  hours  after  labour,  and  as 
a  rule  it  may  be  said  that  the  earlier  the  onset  the  more 
acute  will  be  the  disease.  While  not  invariable,  an  initial 
rigor  occurs  in  the  majority  of  cases  ;  when  regular  tem- 
perature observations  have  been  taken,  a  certain  amount  of 
pyrexia  may  be  found  to  have  preceded  it,  the  temperature 
rising  in  steps  day  by  day.  Headache  and  general  malaise 
also  sometimes  precede  it,  but  often  the  patient  is  quite 
unconscious  of  illness  until  the  onset  of  shivering.  A  severe 
rigor  begins  with  a  sensation  of  cold  so  intense  as  to  cause 
'  chattering  '  of  the  teeth  and  general  muscular  tremors  ;  the 
skin  surface  becomes  cold  to  the  touch,  and  from  spasm  of  the 
erector  pilae  muscles  assumes  the  appearance  of  '  goose-flesh ' ; 
the  face  and  lips  become  somewhat  blue,  and  the  features 
contracted.     The  rectal  temperature  in  a  moderately  severe 


582  THE   PUERPERIUM 

rigor  will  show  a  rise  to  103°  to  105°  E.,  but  106°  to  107°  is 
sometimes  reached  ;  the  pulse  is  very  rapid,  and  at  the  wrist, 
difficult  to  count.  The  shivering  stage  may  be  momentary  or 
may  last  from  ten  to  fifteen  minutes  ;  it  is  succeeded  by  a 
congestive  stage  in  which  the  sensation  of  cold  gives  place  to 
one  of  burning  heat ;  muscular  tremor  ceases,  and  the  face 
becomes  flushed  ;  the  skin  feels  hot  and  is  at  first  dry,  after- 
wards moist.  Severe  headache  often  accompanies  this  stage. 
Then  sweating  sets  in,  and  the  temperature  rapidly  falls 
several  degrees  ;  after  a  rigor  of  exceptional  severity,  it  may 
fall  to  one  to  two  degrees  below  the  normal. 

It  will  be  most  convenient  to  consider  the  general  clinical 
features  one  by  one. 

Temperature. — The  pyrexia  always  runs  an  irregular 
course,  the  general  type  of  which  is  remittent.  Repeated 
rigors  may  recur  at  irregular  intervals  in  cases  of  acute  infec- 
tion ;  but  no  regular  variations  in  the  diurnal  temperature 
occur,  as,  for  instance,  in  typhoid  fever  ;  temperature  charts, 
unless  they  show  at  least  four-hourly  measurements,  are 
therefore  quite  misleading.  There  is,  as  a  rule,  no  apyrexial 
period,  but  a  remission  of  two  or  three  degrees  normally 
occurs  at  some  period  of  each  day.  In  cases  of  moderate 
severity  the  highest  diurnal  temperature  is  about  102°  or 
103°  E.  ;  in  severe  cases  it  may  be  104°  or  105°  E.  Generally 
speaking,  the  pyrexia  is  higher  and  shows  wider  fiuctuations 
than  in  sapreemia. 

While  the  temperature  is,  as  a  rule,  a  fair  index  of  the 
severity  of  the  infection,  its  prognostic  importance  must  not 
be  over-estimated,  severe  pyrexia  and  repeated  rigors,  recur- 
ring during  several  weeks,  being  not  incompatible  with 
recovery.  On  the  other  hand,  very  severe  or  rapidly  fatal 
cases  may  occur  without  very  high  temperature. 

Pulse. — The  pulse-rate  is  always  rapid,  and  is  to  a  great 
extent  independent  of  the  temperature.  The  pulse  may  be 
over  120  with  only  a  moderate  degree  of  fever  ;  in  severe 
cases  it  may  reach  130  to  140  ;  this  disproportionate  rapidity 
of  the  pulse  in  puerperal  illness,  in  the  absence  of  such  com- 
plications as  heart  disease  or  exophthalmic  goitre,  is  an 
almost  certain  indication  of  septicaemia.  Shght  diurnal 
variations  follow  the  fluctuations  of  temperature.  The 
volume  of  the  pulse  is  small,  and  the  tension  low  in  severe 


SEPTICEMIA  583 

cases.  The  rate  and  tension  of  the  pulse  are  of  great  impor- 
tance in  prognosis  ;  a  persistent  pulse-rate  of  over  120  being 
of  grave  significance. 

The  Pelvic  Organs. — In  a  case  of  pure  septicaemia,  the 
uterine  cavity  will  be  found  empty,  and  involution,  as  a  rule, 
will  not  be  markedly  arrested  ;  there  will,  therefore,  be  no 
undue  enlargement  or  tenderness  of  the  uterus.  The  lochial 
discharge  usually  ceases  early  in  a  severe  case,  and  when 
present  may  show  no  sign  of  decomposition.  On  vaginal 
examination  no  local  signs  of  pelvic  inflammation  will  be 
found  in  the  early  stages,  but  vulval,  vaginal,  or  cervical 
lacerations  may  show  signs  of  local  infection. 

The  Blood  in  a  case  of  septicaemia  contains  a  small 
number  of  the  organisms  which  represent  the  infective  agent. 
When  detected  they  afford  a  proof  of  the  septicsemic  nature 
of  the  infection.  In  cases  of  saprsemia  the  blood  is  sterile. 
Intense  anaemia  is  produced  by  septicaemia  when  the  course 
of  the  illness  is  prolonged,  and  there  are  repeated  rigors. 
There  is  also  well-marked  leucocytosis,  which  varies  in 
degree,  but  may  reach  30,000,  with  80  to  90  per  cent,  of  poly- 
morphonuclear cells  ;  the  proportion  of  eosinophile  cells  is 
diminished  in  proportion  to  the  severity  of  the  infection.  A 
high  degree  of  leucocytosis  is  not  of  unfavourable  signi- 
ficance ;  if  there  is  a  local  focus  of  infection  it  may 
indicate  the  formation  of  pus. 

The  Heart. — Cardiac  action  is  unfavourably  affected  by 
degenerative  changes  in  the  muscle,  but  the  gravest  cardiac 
complication  is  ulcerative  endocarditis,  which  may  occur 
either  in  septicaemia  or  pyaemia.  It  is  often  unrecognised 
clinically,  but  may  lead  to  the  formation  of  multiple  septic 
emboli.     It  is  almost  always  fatal. 

Pleurisy,  Pneumonia  and  Metastatic  Pulmonary  Abscesses 
may  occur  in  septicaemia  and  pyaemia.  Later  on,  signs  of 
acute  peritonitis,  either  pelvic  or  general,  or  signs  of  acute 
pelvic  cellulitis  may  be  found. 

Subjects  of  puerperal  sepsis  usually  take  nourishment 
freely,  there  is  no  vomiting,  and  the  digestive  processes  are 
good.  Vomiting  when  it  occurs  is  of  serious  import,  especi- 
ally when  associated  with  abdominal  distension  and  rigidity  ; 
after  some  time  the  vomit  may  become  black  from  admixture 
with  blood,  even  when  the  case  is  not  complicated  by  peri- 


584  THE   PUERPERIUM 

tonitis.  As  a  rule,  persistent  vomiting  indicates  peritonitis, 
but  tympanitic  abdominal  distension  is  frequently  seen  as 
the  result  of  a  general  septicsemic  infection.  Diarrhoea  is  not 
an  infrequent  symptom,  and  may  be  of  service  in  assisting 
the  excretion  of  toxins.  When  uncontrollable  or  involuntary 
it  is  of  serious  omen.  Sleeplessness,  often  accompanied  by 
severe  headache,  may  be  met  with,  and  is  to  be  regarded  as 
another  unfavourable  sign.  Cutaneous  rashes,  of  erythe- 
matous or  papular  type,  are  not  uncommon  ;  they  are 
usually  transient,  and  may  disappear  in  one  part  to  reappear 
in  another.  Profuse  sweating  is  common,  and  may  lead  to 
an  eruption  of  sudamina.  The  urine  is  usually  scanty,  con- 
centrated, and  contains  a  trace  of  albumen.  The  tongue  at 
first  is  moist  but  furred  ;  as  the  disease  progresses  it  becomes 
dry,  and  in  very  severe  cases  brown  and  cracked,  while  sordes 
collect  around  the  teeth.  The  intelligence  is  usually  unim- 
paired, even  in  fatal  cases,  almost  up  to  the  moment  of  death, 
but  delirium  passing  into  coma  sometimes  supervenes  as 
the  end  approaches.  The  mammary  secretion  becomes  sup- 
pressed in  severe  cases  after  the  first  few  days.  Pain  is  an 
infrequent  symptom  of  septicaemia.  In  the  initial  stages 
there  may  be  severe  aching  pain  in  the  back,  limbs,  joints 
and  head,  but  this  does  not  persist.  Abdominal  pain  is  rare 
except  when  there  is  a  local  pelvic  lesion  or  general  peri- 
tonitis. The  joints  and  synovial  sheaths  sometimes  show 
serous  effusions  in  septicaemia,  one  after  another  being 
implicated,  but  the  effusions  are  usually  re-absorbed  without 
suppuration  occurring. 

Diagnosis. — Great  practical  importance  is  attached  to 
bacteriological  examination  of  the  uterine  lochia.  From 
what  has  been  already  said  it  will  be  clear  that  blood 
examination  for  diagnosis  is  uncertain,  as  only  positive 
results  can  be  trusted  absolutely.  Eor  clinical  purposes  the 
diagnosis  of  the  infecting  organism  is  better  made  from 
the  uterine  lochia,  but  very  careful  technique  is  required  in 
obtaining  the  material.  Lochial  swabs  may  be  taken  as 
follows  :  the  vaginal  canal  should  first  be  well  douched  ;  a 
large-size  Ferguson's  speculum  should  next  be  passed  so  as 
to  expose  the  portio  vaginalis  and  shut  off  the  vaginal  walls  ; 
the  surface  of  the  portio  vaginalis  and  the  cervical  canal 
should  next  be  carefully  cleansed  by  swabbing  ;    a  short 


DIAGNOSIS    OF   INFECTION  585 

sterilised  glass  tube  is  then  passed  into  the  cervix,  and  a 
sterile  swab  then  carefully  passed,  without  contact,  into  the 
tube  and  pushed  up  to  the  fundus.  Swabs  of  lochia  thus  taken 
from  the  interior  of  the  uterus  may  yield  pure  cultures  of 
streptococci  or  staphylococci  ;  or  mixed  growths  of  these 
organisms  with  the  bacterium  coli  and  the  pneumococcus 
may  be  obtained.  Bacteriological  examination  of  the 
vaginal  secretion  is  useless  for  diagnosis  ;  it  has  been  some- 
times found  sterile  when  the  uterine  lochia  contained 
pyogenic  cocci,  but  it  usually  contains  pathogenic  and  non- 
pathogenic organisms  even  when  the  uterus  itself  is  not 
infected.  In  clinically  severe  cases  of  puerperal  septicaemia 
the  streptococcus  in  pure  culture  will  be  found  in  roughly 
three-fourths  of  the  cases.  In  the  remainder  a  staphylo- 
coccus in  pure  culture,  the  bacterium  coli,  or  a  mixture  of 
organisms  may  be  found. 

Attempts  have  recently  been  made  to  show  that  strains 
of  streptococci  which  are  capable  of  producing  septicaemia 
are  characterised  by  a  definite  haemolytic  action.  Under 
further  experiments,  however,  this  view  has  broken  down, 
for  it  has  been  shown  that  the  same  haemolytic  power  is 
possessed  by  non-virulent  strains  of  streptococci.  Haemo- 
lytic action  is,  therefore,  of  no  diagnostic  significance. 

It  must  be  borne  in  mind  that  a  mild  fever  of  either 
sapraemic  or  septicaemic  type  may  be  caused  by  infection  of 
wounds  of  the  lower  part  of  the  genital  tract — cervix,  vagina, 
vulva,  and  perineum — while  the  uterus  itself  remains  free 
from  infection.  These  parts  should,  accordingly,  always  be 
examined,  and  the  condition  of  wounded  surfaces  carefully 
noted. 

The  distinction  between  sapraemia  and  septicaemia  may 
often  be  made  by  attention  to  the  condition  of  the  uterus  and 
the  lochia,  and  to  the  effects  of  intra-uterine  disinfection. 

In  cases  of  difficulty  it  should  be  the  rule  to  regard  as 
septic  in  origin  all  cases  of  pyrexia  in  the  puerperium  for 
which  some  other  cause  cannot  be  clearly  demonstrated. 
Such  disorders  as  influenza,  scarlet  fever,  and  enteric  fever 
may  no  doubt  attack  lying-in  women  and  produce  a  train  of 
symptoms  resembling  those  of  septicaemia  ;  but  they  must 
never  be  loosely  diagnosed,  although  the  temptation  to  do 
so  may  sometimes  be  difficult  to  resist. 


586  THE   PUERPERIUM 

Prognosis. — At  the  onset  of  a  case  of  uterine  infection 
the  prognosis  must  always  be  guarded.  If  a  well-marked 
improvement  follows  the  local  treatment  described  later  on, 
the  prognosis  is  good,  for  the  infection  is  then  mainly 
saprsemic.  Yet  a  case  which  begins  as  one  of  saprsemia  may 
later  on  develop  into  one  of  generahsed  infection.  In  a  case 
of  simple  and  uncomplicated  saprsemia  the  prognosis  is 
always  good  and  practically  all  cases  end  in  recovery.  In 
septicaemia  the  prognosis  is  much  less  favourable  than  in 
saprsemia,  because  the  infection  is  more  vnulent  in  type,  and 
the  general  symptoms  are  more  severe. 

The  course  of  septicaemia  may  be  greatly  prolonged  ; 
after  considerable  improvement  has  occurred,  serious 
relapses  may  supervene,  and  local  affections  such  as  phleg- 
masia or  salpingitis  may  appear.  Sometimes  the  case 
terminates  in  pyaemia.  A  moderate  degree  of  leucocytosis 
is  of  good  prognosis  ;  a  sudden  faU  is  of  serious  import, 
and  a  rapid  rise  associated  with  the  formation  of  localised 
inflammatory  effusions  usually  indicates  suppuration.  The 
symptoms  of  gravest  prognostic  significance  are  the 
following  : — 

(1)  Pulse-rate  persistently  over  120. 

(2)  Persistent  vomiting  and  tympanites,  with  dry  brown 

tongue. 

(3)  Sleeplessness. 

(4)  Repeated  severe  rigors. 

(5)  Inabflity  to  take  sufficient  nourishment. 
Estimates  by  different  observers  of  the  rate  of  mortality 

of  puerperal  septicaemia  vary  greatly  ;  this  is  not  surprising 
when  the  varied  degrees  of  severity  which  may  be  met  with 
are  borne  in  mind.  Thus  Kronig  and  ^'\^itridge  Williams 
have  each  reported  fifty  cases  of  streptococcic  infection  with 
a  mortahty  of  only  4  per  cent.  On  the  other  hand,  a  series 
of  one  hundred  cases  of  streptococcic  infection  collected 
from  various  sources  by  the  American  Gynaecological  Society 
yielded  a  mortahty  of  nearly  30  per  cent.  Lea  states  the 
general  mortahty,  including  mild  cases,  to  be  about  10  per 
cent.,  but  in  severe  cases  it  is  probably  as  high  as  65  to  70 
per  cent.  The  prompt  recognition  of  the  condition,  and  the 
prompt  adoption  of  suitable  treatment,  will  always  favour- 
ably influence  the  patient's  chances  of  recovery. 


TREATMENT   OF  INFECTION  587 

Treatment. — The  importance  of  the  'prophylaxis  of  puer- 
peral infection  by  strict  antiseptic  routine,  by  avoidance  of 
unnecessary  examinations  or  operative  interference,  and  by 
the  careful  and  proper  management  of  the  third  stage  of 
labour,  has  been  already  frequently  insisted  upon.  When 
once  the  disease  has  manifested  itself,  treatment  must  be 
promptly  applied,  for  like  most  wound-infections,  only  in 
the  earliest  stages  can  its  spread  be  controlled.  Inasmuch 
as  the  differential  diagnosis  of  saprsemia  and  septicaemia  can 
seldom  be  made  immediately,  the  initial  treatment  must 
follow  the  same  general  principles  for  all  cases,  and  will 
depend  upon  the  severity  of  the  symptoms  rather  than  the 
nature  of  the  infection. 

Mild  Type. — Temperature  101°  to  102°  F.  ;  no  shivering 
or  rigor  ;  headache  slight ;  uterus  large  ;  lochia  often  but 
not  always  offensive.  Such  cases  are  probably  sapraemic, 
and  the  dose  of  toxins  absorbed  into  the  general  circulation 
is  small.  They  can  usually  be  cured  by  hot  vaginal  douching 
with  a  mild  antiseptic  (lysol,  a  teaspoonful  to  a  pint), 
ergot  in  fuU  doses  (ergotin,  3  grains  three  times  a  day),  and 
free  purgation.  Douching  and  the  administration  of  ergot, 
by  stimulating  the  uterine  muscle,  promote  drainage  and 
assist  the  expulsion  of  retained  dead  tissues  ;  purgation 
assists  the  elimination  of  the  absorbed  toxins.  Uterine 
drainage  is  assisted  by  keeping  the  patient  in  a  sitting 
position  as  much  as  possible.  In  two  or  three  days  the 
symptoms  will  subside. 

Severe  Type. — Temperature  103°  F.  or  higher  with  or 
without  a  rigor  ;  pulse  100  to  120  ;  headache  and  general 
malaise  well  marked  ;  condition  of  lochia  unimportant,  but 
may  be  scanty  and  inoffensive,  or  profuse  and  foetid.  In  all 
such  casfe^  it  is  best  to  begin  the  treatment  by  careful  and 
thorough  disinfection  of  the  uterine  cavity.  It  will  be 
remembered  that  in  saprsemia  the  chief  focus  of  infection  is 
the  wall  of  the  uterus,  which  shows  the  changes  described  as 
putrid  endometritis.  This  can  only  be  adequately  dealt  with 
by  clearing  all  debris  out  of  the  uterus,  and  thoroughly 
douching  the  uterine  cavity  with  a  large  quantity  of  a 
suitable  antiseptic  solution. 

In  clearing  oat  the  uterus,  an  anaesthetic,  although  not 
always  necessary,  is  desirable,  because  it  allows  of  the  opera- 


588  THE   PUERPERIUM 

tion  being  more  thoroughly  performed.  The  patient  should 
be  placed  in  the  modified  lithotomy  position,  and  the  operator 
should  protect  his  own  hands  from  infection  by  wearing 
sterilised  rubber  gloves.  A  swab  for  bacteriological  diag- 
nosis should  be  first  taken  in  the  manner  already  described. 
Mechanical  dilatation  of  the  cervix  is  never  required 
during  the  first  week  of  the  puerperium.  After  thoroughly 
douching  and  swabbing  the  vulva  and  vagina,  one  or  two 
fingers  can  be  passed  directly  into  the  uterus,  and  the  walls 
carefully  scraped  with  the  protected  finger-tip  until  all 
debris  has  been  removed.  Pieces  of  adherent  membrane  or 
placenta  may  be  encountered,  the  separation  of  which  will 
cause  fairly  free  bleeding.  A  blunt  wire  curette  (Fig.  273) 
may  be  used  for  scraping  the  walls,  but  the  ordinary  sharp 
curette  should  not  be  employed  during  the  first  week  of  the 
puerperium  ;  this  instrument  removes  too  much  of  the  soft 


Fig.  273. — Blunt  Curette. 


uterine  wall,  destroys  the  protective  leucocytic  zone,  and 
opens  up  fresh  channels  through  which  generalised  infection 
may  occur.  It  may  also  very  easily  perforate  the  uterine 
wall.  It  is  of  Httle  use  to  douche  the  uterus  without  first 
clearing  the  walls  in  this  way,  for  douching  alone  will  not 
detach  adherent  fragments  of  placenta  or  membrane. 

The  uterine  cavity  should  then  be  douched  with  3  or  4 
pints  of  a  hot  antiseptic  solution  (115°  P.).  Solutions  in 
common  use  for  this  purpose  are  lysol,  izal,  cyllin  (5SS  to 
Oj),  or  tincture  of  iodine  (53  to  Oj),  or  carbolic  acid  (1  in 
60),  or  biniodide  or  perchloride  of  mercury  (1  in  4,000)  ;  if 
the  latter  is  employed  a  quart  of  normal,  sterile,  saHne  solu- 
tion, or  plain  boiled  water,  should  be  used  immediately 
afterwards  to  wash  out  any  excess  of  the  mercurial  solution 
which  might  otherwise  remain  in  the  uterus,  and  become 
absorbed.  If  this  precaution  is  adopted  there  is  no  risk  of 
mercurial    poisoning.     Probably    the    most    useful    of    all 


TREATMENT   OF   INFECTION  589 

solutions  for  intra-uteriiie  douching  in  sepsis  is  a  dilute 
solution  of  peroxide  of  hydrogen  (about  5  volumes).  This  is 
absolutely  non-toxic,  and  its  deodorant  power  is  much 
greater  than  that  of  the  usual  antiseptics,  while  its  bacteri- 
cidal strength  is  at  any  rate  equal  to  them.  It  is  unnecessary 
to  douche  the  uterus  frequently,  all  that  is  practicable  will 
be  accompKshed  by  a  single  douching  if  the  uterine  cavity  has 
first  been  cleared  out.  The  action  of  the  intra-uterine  douche 
is  chiefly  mechanical,  its  bactericidal  powers  being  probably 
very  small.  In  douching  the  uterine  cavity  a  long  glass 
nozzle  with  a  grooved  return  channel,  such  as  that  shown 
in  Fig.  274,  should  be  employed,  or  one  of  pewter,  which  is 
unbreakable  and  can  be  bent  to  any  required  shape,  may  be 


Fig.  274. — Glass  Intra-uterine  Douche  Nozzle,  grooved  to  allow  a 
return  flow. 

preferred  ;  it  can  be  sterihsed  by  boiling.  Care  should  be 
taken  to  maintain  full  uterine  retraction  afterwards  by  the 
administration  of  ergot  in  f uU  doses  ;  retention  of  clot  from 
the  oozing  surfaces  will  thus  be  prevented. 

Before  exploring  the  uterine  cavity,  lacerations  of  the 
lower  part  of  the  genital  tract  should  be  looked  for  and  their 
condition  carefully  noted.  They  will  usually  be  found  un- 
healthy, with  more  or  less  sloughing  ;  they  should  be  care- 
fully cleansed  by  swabbing,  and  then  freely  painted  with 
pure  carbolic  acid. 

If  the  case  is  one  of  simple  saprsemia,  this  treatment, 
combined  with  the  administration  of  purgatives,  in  most 
cases  rapidly  cures  the  patient.  Temperature  and  pulse 
fall  to  normal  in  two  or  three  days,  or  even  sooner,  as  the 
toxms  are  ehminated  ;  reduction  in  size  of  the  uterus  takes 
place  ;   the  lochia  become  once  more  odourless  and  usually 


590  THE   PUERPERHJM 

very  scanty  in  amount.  No  further  local  treatment  is  then 
required  except  that  the  vagina  should  be  douched  twice 
daily  for  several  days.  Complete  failure  of  this  treatment 
indicates  that  generalisation  of  the  septic  process  has 
occurred.  Occasionally  cases  are  met  with  in  which  con- 
siderable-sized pieces  of  putrid  placental  tissue  are  found 
in  the  uterus,  associated  with  severe  symptoms  of  infection. 
The  removal  of  such  placental  remains  by  mechanical  means 
is  often  accompanied  by  severe  bleeding  and  followed  by 
great  exacerbation  of  the  symptoms,  the  explanation  being 
that  laceration  of  vessels  allows  of  the  rapid  entrance  into 
the  circulation  of  large  doses  of  toxic  materials,  and  of  the 
general  dissemination  of  organisms  by  the  blood  stream. 
Accordingly,  some  teachers  advise  that  such  cases  should 
not  be  dealt  with  by  operative  measures  at  all,  but  the 
spontaneous  separation  of  the  placental  tissues  should  be 
awaited,  loose  pieces  being  removed  by  irrigation.  Fre- 
quently, however,  severe  recurrent  attacks  of  bleeding  occur 
in  such  cases,  and  the  removal  of  the  placental  remains  is 
the  wiser  course  in  all  cases.  The  operator  should  use 
blunt  instruments  only,  and  freely  douche  the  uterus  after- 
wards. A  septic  uterus  should  of  course  never  be  packed, 
neither  should  strong  antiseptics  capable  of  exerting  a 
caustic  action  on  the  uterine  wall  be  employed.  Such  an 
effect  reduces  the  vitaUty  of  the  uterine  tissues,  and  diminishes 
their  power  of  resisting  the  spread  of  the  infection. 

When  it  appears  probable  that  the  case  is  one  of  septi- 
caemia, three  lines  of  treatment  are  available — viz.,  (a)  specific, 
(b)  general,  and  (c)  surgical. 

(a)  Specific  Treatment. — The  specific  treatment  of  an 
infective  process  consists  in  an  attempt  to  establish  arti- 
ficially a  condition  of  immunisation  against  the  particular 
infective  agent  present.  Immunity  is  attained  by  the  intro- 
duction of  certain  organic  substances  which  are  antagonistic 
or  antidotal  to  the  infective  bacteria  themselves,  or  to  the 
toxins  which  they  produce.  This  imitates  the  natural 
processes,  in  which  spontaneous  recovery  from  an  infection 
is  the  result  of  the  destruction  of  the  infective  organisms  and 
their  toxins  by  '  anti-bodies  '  produced  by  the  tissues  of  the 
host.  The  condition  of  immunity  thus  produced  may  be 
maintained  for  more  or  less  prolonged  periods,   and  this 


TREATMENT   OF   INFECTION  591 

will  enable  the  body  to  resist  successfully  any  fresh  infection 
of  the  same  nature.  The  process  of  artificial  immunisation 
may  be  attempted  in  one  of  two  ways  :  (1)  Fully  formed 
anti-bodies  may  be  introduced  derived  from  the  blood  of  an 
animal  which  has  just  recovered  from  the  same  infection  and 
is  therefore  immune  ;  the  various  antitoxic  sera  are  of  this 
nature.  Most  of  them  act  by  destroying  the  bacteria  them- 
selves which  are  growing  in  the  tissues  of  the  body  ;  others 
act  by  destroying  or  neutralising  the  toxins  which  these 
organisms  have  produced.  (2)  An  artificial  pure  culture  may 
be  made  of  the  infective  organisms  obtained  from  the  fluids 
of  the  patient.  From  the  artificial  culture  thus  obtained  a 
standardised  emulsion  is  prepared  containing  a  known 
number  of  bacteria  per  cubic  centimetre  ;  the  organisms  are 
then  destroyed  by  heat,  the  emulsion  being  thus  rendered 
sterile.  The  injection  of  these  dead  bacteria  into  the  tissues 
of  the  host  stimulates  the  natural  production  of  certain  pro- 
tective materials  in  the  blood  (opsonins),  and  thus  increases 
the  power  of  the  body  to  overcome  the  infective  process. 
All  vaccines  are  of  this  description. 

Antitoxic  sera  can  at  present  be  obtained  for  strepto- 
coccic, staphylococcic,  and  bacillus  coli  infections  or  for 
combinations  of  these  organisms  ;  for  the  numerous  other 
organisms  which  may  be  concerned  in  producing  puerperal 
infection  physiological  antidotes  are  not  available,  with  the 
exception  of  the  diphtheritic  and  the  typhoid  bacilli.  It  is 
generally  believed  that  streptococci  are  the  most  virulent 
of  the  pyogenic  cocci,  and  antistreptococcic  serum  has  accord- 
ingly been  freely  used  in  puerperal  septicaemia,  even  when 
a  bacteriological  diagnosis  has  not  been  made.  The  results 
of  its  use  have  been,  on  the  whole,  unsatisfactory.  This  is 
probably  to  be  attributed  in  part  to  the  fact  that  strepto- 
cocci are  not  always  the  infecting  organisms,  and  in  part  to 
the  fact  that  there  are  many  different  sub-species  of  strepto- 
cocci, each  requiring  its  own  antitoxin  ;  it  is  therefore 
difficult  to  prepare  a  serum  which  will  efficiently  antagonise 
the  species  which  may  chance  to  be  present  in  any  particular 
case.  An  attempt  to  do  so  has  been  made  in  the  preparation 
of  the  polyvalent  serum,  which  is  obtained  from  an  admixture 
of  various  species  of  streptococci.  In  applying  this  treat- 
ment, exact  bacteriological  diagnosis  is  obviously  of  great 


592  THE   PUERPERIUM 

importance.  In  the  rare  cases  which  appear  to  be  due  to 
the  diphtheria  or  typhoid  bacilli,  the  special  sera  of  these 
organisms  may  be  administered. 

Antistreptococcic  serum  should  be  given  by  subcutaneous 
injection  in  the  abdomiual  wall  or  the  thigh.  The  glass 
s\Tuige  used  should  be  carefully  boiled,  and  the  strictest 
antiseptic  precautions  employed  in  regard  to  the  preparation 
of  the  skin,  etc.  The  first  dose  administered  should  be  at 
least  15  cubic  centimetres,  which  ma}^  be  repeated  every 
twelve  hours  for  several  days  ;  larger  doses  have  been 
frequently  given  without  ill-effects.  Improvement  is  indi- 
cated by  f  aU  of  temperature  and  pulse,  cleaning  of  the  tongue, 
and  amelioration  of  the  general  symptoms.  If  no  improve- 
ment follows,  it  is  useless  to  persist.  Its  injection  in  similar 
dose  into  foci  of  infection,  such  as  pelvic  inflammatory 
effusions,  has  also  been  recommended. 

Vaccine  Treatment  is  not  so  simple,  and  appears  to  require 
more  exact  observation  than  serum  treatment.  According 
to  Sir  Aim  roth  Wright,  estimation  of  the  opsonic  index,  i.e., 
the  proportion  of  the  protective  substances  present,  should  be 
carried  out  at  regular  intervals  duriag  this  treatment.  This 
is  not,  however,  regarded  as  necessary  by  aU  bacteriologists. 
The  vaccine  is  supplied  in  sealed  glass  capsules,  each  con- 
taining a  certain  number  (estimated)  of  bacteria.  It  should 
be  given  with  the  same  strict  antiseptic  precautions  as  the 
serum.  The  initial  dose  should  be  a  small  one  in  a  case  of 
puerperal  septicsemia,  e.g.  5,000,000;  this  dose  may  be  repeated 
at  intervals  of  three  or  four  days  and  gradually  increased  up 
to  30,000,000  or  40,000,000  if  improvement  follows  and  the 
reaction  is  not  too  marked.  The  preparation  of  a  vaccine 
requires  an  expert  bacteriologist,  and  as  it  involves  con- 
siderable expense  it  is  at  present  only  available  under  very 
restricted  conditions. 

Results  of  Specific  Treatment. — Antitoxic  sera  have  now 
been  freely  used  for  several  years,  and  it  must  be  admitted 
that  the  results  are  disappointing.  While  no  harm  appears 
to  follow,  it  cannot  be  said  that  these  remedies  have  been 
shown  to  exert  a  decided  influence  in  diminishing  either  the 
length  or  the  severity  of  the  infective  process.  Very  favour- 
able results  have  recently  been  reported  by  treatment  with 
an  autogenous  vaccine  obtained  from  cultures  of  the  uterine 


TREATMENT   OF   INFECTION  593 

lochia  in  a  series  of  ninety-six  cases  by  Western.  Further 
observations  are,  however,  required  before  the  question  can 
be  regarded  as  definitely  settled.  It  seems  desirable,  how- 
ever, to  make  use  of  both  vaccines  and  antitoxins  when 
possible  in  all  severe  cases,  exact  bacteriological  diagnosis 
of  the  nature  of  the  infection  having  been  first  made. 

(b)  Geyieral  Treatment.— Food  should  be  mostly  fluid,  and 
milk  naturally  forms  the  most  important  item  ;  3  to  4 
pints  are  often  readily  taken  even  by  patients  who  are  seri- 
ously ill.  Meat  extracts,  soups  and  jellies  may  be  added. 
Alcohol  is  not  required  in  mild  cases  and  is  undesirable  in 
large  doses  owing  to  its  depressant  action  on  the  heart.  In 
small  doses  it  does  good  when  there  is  difficulty  in  getting 
the  patient  to  take  sufficient  nourishment.  If  the  bowels 
are  constipated  a  mild  aperient  should  be  given  every  other 
night  ;  moderate  diarrhoea  may  be  allowed  to  continue 
unchecked  ;  severe  diarrhoea  should  be  controlled  by  adminis- 
tering starch  and  opium  enemata.  Pyrexia  should  not  be 
directly  treated  unless  the  temperature  rises  over  104°  F. 
Antipyretics  should  not  be  given,  but  the  use  of  the  wet  pack 
or  tepid  sponging  may  be  relied  upon  when  necessary.  Sleep- 
lessness when  present  should  be  controlled  by  hypnotics,  such 
as  veronal  or  sulphonal  in  doses  of  7  to  10  grains,  which 
may  be  given  every  night  for  a  time  if  required.  Sub- 
cutaneous saline  transfusion  stimulates  leucocytosis  and 
phagocytosis,  and  promotes  elimination  by  the  sldn  and 
kidneys.  It  may  therefore  be  employed  with  advantage  in 
the  acute  stages,  a  pint  of  fluid  being  introduced  twice  a 
day  for  several  days  ;  or  a  graduated  continuous  rectal 
injection  may  be  used  for  several  hours  a  day. 

(c)  Surgical  Treatment. — Attempts  have  been  made  in 
recent  years  to  show  that  removal  of  the  uterus  is  capable  of 
favourably  influencing  the  course  of  severe  cases  of  puerperal 
septicaemia.  Advocates  of  this  operation  contend  that  as 
the  uterus  is  the  chief,  if  not  the  sole,  focus  of  infection,  its 
removal  will  arrest  the  continuous  passage  into  the  circu- 
lation of  fresh  organisms  and  toxins,  produced  by  the 
active  bacterial  development  proceeding  in  it.  It  is,  how- 
ever, certaia  that  in  severe  cases  of  septicaemia  widespread 
dissemination  of  organisms  which  multiply  in  the  lymph  or 
blood  streams  has  already  occurred  ;   removal  of  the  uterus 

E.M.  38 


594  THE   PUERPERIUM 

"under  such  circumstances  cannot  arrest,  although  it  may 
modify,  the  general  infective  process,  and  therefore  is  not 
to  be  regarded  as  a  radical  operation.  The  latter  view  is 
upheld  by  the  unfavourable  results  of  this  operation,  for  up 
to  the  present  it  has  not  been  shown  to  increase  the  patient's 
chances  of  recovery.  In  the  absence  of  local  pelvic  lesions 
this  operation  should  not  be  performed,  but  when  an  infected 
fibroid  tumour  is  present,  when  the  uterus  has  been  ruptured 
or  perforated,  or  when  there  is  evidence  of  abscess  forma- 
tion in  the  uterine  wall,  the  removal  of  the  uterus  may  be 
necessary. 

2.  General  Puerperal  Peritonitis. — The  results  of  post- 
mortem examinations  show  that  this  condition  is  infrequent. 
Some  of  the  symptoms  of  general  peritonitis — e.g.,  con- 
tinuous vomiting,  meteorism,  irregular  pyrexia,  and  a  rapid 
small  pulse — are  met  with  in  puerperal  septicaemia.  The 
clinical  diagnosis  of  general  peritonitis  may  accordingly 
present  unusual  difhculties  in  cases  of  puerperal  infection.  A 
systematic  description  of  the  clinical  features  of  this  affection 
is  unnecessary  in  a  text-book  of  midmfery,  for  it  differs  little 
from  general  peritonitis  due  to  surgical  causes,  the  distinctive 
symptoms  being  abdominal  pain  and  rapidly  increasing  dis- 
tension accompanied  by  nausea  and  vomiting,  the  latter 
sometimes  persistent.  The  prognosis  is  very  serious,  but 
free  drainage,  suprapubic,  vaginal,  and  lumbar,  should  be 
established  as  soon  as  the  diagnosis  is  made,  and  the 
same  general  and  specific  treatment  apphed  as  in  cases  of 
septicaemia. 

3.  Local  Pelvic  Inflammation. — A  well-defined  group  of 
cases  of  puerperal  infection  may  be  recognised,  of  which  the 
main  feature  is  the  presence  of  pelvic  inflammatory  lesions — 
i.e.,  of  course,  lesions  outside  the  uterus.  In  such  cases  the 
inflammatory  process  is  seldom  limited  to  a  single  tissue  or 
a  single  organ,  yet  it  ordinarily  manifests  itself  chiefly  in 
either  the  pelvic  peritoneum,  the  pelvic  cellular  tissue,  or  the 
uterine  appendages.  Thus,  with  pelvic  ceUuhtis  more  or 
less  peritonitis  is  usually  found  as  an  accompaniment,  while 
with  pelvic  peritonitis  the  Fallopian  tubes  and  ovaries  are 
necessarily  implicated  to  a  greater  or  less  extent.  The 
relative  frequency  of  occurrence  of  this  group  of  local 
puerperal  infections  is  probably  not  more  than  1  in  10  of  all 


LOCAL   INFECTION  595 

cases.  The  original  focus  of  infection  is,  in  almost  all  cases, 
the  uterus  ;  thence  the  process  spreads  by  direct  continuity 
through  the  Fallopian  tubes  to  the  pelvic  peritoneum,  or 
through  a  cervical  tear  to  the  cellular  tissue  ;  or  it  may 
spread  through  the  lymphatics  of  the  uninjured  cervix  to  the 
cellular  tissue  ;  or  through  the  lymphatics  of  the  uterine 
wall  to  the  peritoneum.  Occasionally  the  veins  appear  to 
be  the  chief  channels  of  infection,  and  a  spreading  phlebitis 
occurs  which  may  pass  downwards  to  the  femoral  vein,  or 
upwards  to  the  inferior  vena  cava.  The  comparative 
rarity  with  which  localised  pelvic  inflammation  follows 
uterine  infection  is  probably  due,  in  some  way,  to  the  pro- 
tection afforded  by  the  zone  of  leucocytic  activity  in  the 
affected  uterine  wall  (see  p.  573). 

Common  Features. — Cases  of  puerperal  pelvic  inflamma- 
tion are  probably  due  to  pyogenic  organisms  of  somewhat 
attenuated  virulence,  or  to  auto-infection  by  the  diplococcus 
gonorrhoeae  ;  sometimes  also  to  bowel  infection  by  the 
bacillus  coli  communis.  It  is  usually  stated  that  they  are 
characterised  by  a  late  onset,  but  this  is  not  strictly  accurate. 
Severe  symptoms  do  not  as  a  rule  appear  earlier  than  the 
latter  half  of  the  first  week — i.e.,  about  the  fifth  or  sixth  day, 
but  slight  symptoms  of  uterine  infection,  often  overlooked, 
are  almost  always  present  earlier  than  this.  When  such 
symptoms  as  moderate  elevation  of  temperature  and  decom- 
position of  the  lochia  are  disregarded,  the  real  onset  of  the 
disease  is  naturally  misunderstood.  It  is  quite  possible  that 
if  due  heed  were  paid  to  the  significance  of  these  symptoms 
in  such  cases,  the  appearance  of  the  local  inflammation  might 
be  altogether  prevented  by  early  and  appropriate  treatment. 
A  rigor  often  occurs,  and  pelvic  pain,  practically  unknown 
in  sapraemia  and  septicaemia,  is  a  prominent  symptom  of 
the  onset  of  some  of  these  affections.  Their  general  course 
is  prolonged,  localised  suppuration  is  not  uncommon,  but  a 
fatal  termination  is  rare.  Mild  cases,  not  marked  by  an 
acute  onset,  are  probably  of  frequent  occurrence,  and, 
being  overlooked  or  inadequately  treated,  pass  into  the  phase 
of  chronic  felvic  inflammation  so  often  met  with  in  parous 
women  of  all  classes  of  life. 

Pelvic  Cellulitis  (synonyms  :  Parametritis,  Broad-liga- 
ment Phlegmon). — Systematic  descriptions  of  this  affection 

38—2 


596  THE   PUERPERIUM 

are  usually  given  in  text-books  of  gynaecology  ;  a  few  points 
only  require  notice  in  the  present  connection. 

An  extensive  cellulitic  effusion  forms  a  hard  immovable, 
non-tender  swelling  which  may  fill  the  entire  pelvis  and  sur- 
round the  uterus  ;  or  may  be  limited  to,  or  chiefly  apparent 
in,  one  or  other  broad  ligament.  In  the  former  case  the 
position  of  the  uterus  is  unaltered  ;  in  the  latter  the  uterus 
is  displaced  to  the  unaffected  side.  In  the  early  stages 
when  the  amount  of  effusion  is  small,  the  swelling,  being 
lateral  in  position  and  not  immovable,  is  difficult  to  dis- 
tinguish from  an  inflamed  tube  and  ovary.  After  a  few  days 
the  characteristic  spread  of  a  cellulitic  effusion  clears  up  the 
diagnosis.  Spreading  along  the  ceUular  tissue  planes  the 
effusion  may  pass  upwards  to  the  iliac  fossa  and  the  abdo- 
minal wall,  forming  a  swelling  palpable  by  abdominal 
examination  above  the  inner  haK  of  Poupart's  ligament,  or 
may  track  upwards  along  the  ilio-psoas  muscle  to  the  region 
of  the  kidney. 

In  some  cases  a  small  effusion  only  is  formed,  which 
occurs  clinically  as  an  ill-defined,  firm  swelling,  placed 
laterally  to  the  uterus,  and  showing  a  limited  amount  of 
mobility  ;  this  usually  subsides  in  from  one  to  two  weeks  ; 
a  more  extensive  swelling  usually  persists  for  several  weeks, 
but  even  those  of  large  size  as  a  rule  ultimately  become 
absorbed.  Sometimes  suppuration  occurs,  indicated  by 
sharp  irregular  rises  of  temperature,  rigors,  exacerbation 
of  pain,  and  marked  increase  in  the  degree  of  leucocytosis — 
always  present  in  pelvic  inflammation.  Cellulitic  abscesses 
usually  point  either  above  Poupart's  ligament,  or  in  one  or 
other  lateral  vaginal  fornix  ;  more  rarely  they  rupture 
into  the  rectum  or  bladder.  Occasionally  they  pass  out  of 
the  pelvic  cavity  through  the  sciatic  or  obturator  foramen,  to 
appear  on  the  buttock  or  the  anterior  aspect  of  the  thigh.  In 
rare  cases  of  extensive  effusion  absorption  takes  place  around 
the  uterus,  leaving  the  pelvis  practically  free,  while  outlying 
parts  of  the  effusion  persist  and  ultimately  suppurate, 
forming  abscesses  in  such  situations  as  the  iliac  fossa  or  near 
the  kidney.  This  condition  has  been  named  remote  para- 
metritis. 

Pelvic  Peritonitis  {Perimetritis)  and  Salpingo-oophoritis. — 
A  peritonitic  pelvic  effusion  usually  occupies  the  pouch  of 


LOCAL    INFECTION  597 

Douglas  ;  it  therefore  forms  a  swelling  behind  the  uterus,  and 
when  of  large  size  it  displaces  this  organ  forwards.  It  is  of 
softer  consistence  than  a  cellulitic  effusion,  and  much  more 
tender  to  touch.  A  roof  of  matted  tissues,  comprising 
omentum  and  large  or  small  bowel,  is  formed  above  it ;  this 
roof  may  be  recognisable  as  an  abdominal  swelling  occupying 
the  hypogastrium,  tender  to  touch,  ill-defined  in  outline,  and 
sub-resonant  on  percussion.  These  ejffusions  rarely  suppurate ; 
when  suppuration  does  occur  the  resulting  abscess  may  be 
spontaneously  evacuated  either  into  the  vagina,  the  rectum, 
or  some  other  part  of  the  bowel.  Spontaneous  absorption 
without  formation  of  pus  occurs  in  the  majority  of  cases,  and 
is  usually  more  rapid  than  in  the  case  of  cellulitis. 

Acute  tubal  or  ovarian  infiammation,  leading  to  the  rapid 
formation  of  a  pyosalpinx  or  an  ovarian  abscess,  is  rarely  met 
with  in  the  puerperium.  Chronic  inflammatory  affections  of 
these  organs,  insidious  in  onset,  and  not  leading  immediately 
to  acute  symptoms,  are,  however,  not  uncommon  sequels  of 
puerperal  infection  ;  they  are  usually  overlooked  until  the 
appearance  of  some  complication,  or  the  chronic  ill-health  of 
the  patient,  leads  her  to  seek  advice. 

Cystitis  may  occur  in  the  puerperium  from  use  of  the 
catheter,  or  more  rarely  from  spontaneous  ascending 
infection  per  urethram,  but  it  does  not  differ  from  the  same 
condition  as  met  with  under  other  circumstances. 

Thrombo-phlebitis . — The  occurrence  of  septic  phlebitis 
accompanied  by  thrombosis  in  the  deep  uterine  veins  in 
septic  conditions  has  been  already  mentioned.  This  process 
may  spread  by  continuity  along  the  ovarian  veins  or  into 
the  iliac,  or  femoral  veins,  and  in  severe  cases  may  ascend 
into  the  inferior  vena  cava.  This  change  plays  an  important 
part  in  the  production  of  pyaemia,  and  when  localised  in  the 
femoral  or  external  iliac  vein  it  produces  one  form  of  phleg- 
masia dolens.  Acute  cases  of  pelvic  thrombo-phlebitis  are 
characterised  clinically  by  the  occurrence  of  repeated  and 
severe  rigors  ;  in  many  mild  cases,  only  slight  rise  of  tempera- 
ture and  quickening  of  pulse  result  from  it.  Sometimes  veins 
in  distant  parts,  and  especially  the  lower  limbs,  become  thus 
affected  during  the  puerperium,  especially  if  varicose  con- 
ditions are  present.  There  is  little  doubt  that  they  are  due 
to  a  mild  form  of  infection. 


598  THE   PUERPERIUM 

The  treatment  of  pelvic  phlebitis  is  that  of  septic  infection 
generally  ;  when  affecting  the  lower  limb  it  should  be  immo- 
bilised by  bandaging  it  lightly  to  a  pillow,  and  hot  fomenta- 
tions appHed  over  the  affected  vein  until  the  pain  and  tender- 
ness disappear.  The  limb  must  be  kept  at  rest  until  the 
intravenous  clot  is  firmly  organised. 

Treatment  of  Local  Pelvic  Inflammations. — The  general 
and  specific  treatment  of  sej^ticsemia  already  described  is 
appHcable  to  these  cases  also.  Disinfection  of  the  uterine 
cavity  should  be  practised  promptly  upon  the  appearance  of 
acute  local  symptoms,  and  before  the  pelvic  inflammatory 
effusions  have  had  time  to  become  extensive.  At  periods 
later  than  this  intra-uterine  treatment  is  of  Uttle  use.  Pro- 
longed confinement  to  bed,  with  careful  feeding  and  nursing, 
and  attention  to  the  daily  evacuation  of  the  bowels,  will  in 
most  cases  lead  to  the  absorption  of  the  effusion.  Collections 
of  pus  should  be  evacuated  without  delay,  the  incision  being 
made  in  the  position  indicated  by  softening  ;  but  the  diag- 
nosis of  suppuration  is  sometimes  difficult,  for  the  abscess 
may  form  in  a  position  inaccessible  to  clinical  examination. 
Incisions  into  cellulitic  areas  should  not  be  made  until  the 
local  signs  of  suppuration  appear.  Careful  and  repeated 
estimation  of  the  number  of  leucocytes  in  the  blood  may  be  of 
great  assistance  in  diagnosis  ;  when  the  number  present  is 
25,000  per  cubic  centimetre  or  over,  with  a  high  percentage  of 
eosinophile  cells,  the  presence  of  pus  is  highly  probable. 

4.  Phlegmasia  alba  dolens  (White  Leg). — This  condition 
when  well  marked  consists  in  a  general  swelling  of  the 
affected  limb  from  the  foot  to  the  groin,  its  onset  being 
attended  by  severe  pain,  pyrexia,  and  general  malaise. 
Although  in  the  great  majority  of  cases  it  affects  the  lower 
limbs  only,  in  a  few  rare  cases  an  upper  limb  has  been  simul- 
taneously or  subsequently  attacked.  Two  varieties,  the 
thrombotic  and  lymphatic,  may  be  distinguished. 

Thrombotic  Form. — In  this,  the  most  frequent  form,  the 
immediate  cause  of  the  sw^eUing  is  phlebitis  of  the  external 
ihac  or  femoral  vein,  leading  to  thrombosis,  and  obstruction 
to  the  venous  return  from  the  limb.  In  the  upper  part  of 
Scarpa's  triangle  the  thrombosed  vein  can  be  readily  felt  as  a 
firm,  somewhat  nodular  and  tender,  thick  cord.  The  swell- 
ing of  the  limb  is  due  to  rapidly  developing  oedema,  which 


PHLEGMASIA  599 

appears  first  in  the  foot  and  quickly  extends  to  the  thigh  ; 
the  swollen  parts  are  soft  and  pit  on  pressure,  and  are  at 
first  of  a  dusky  blue  rather  than  a  white  colour.  Usually  the 
femoral  vein  is  involved  by  continuous  spread  from  similarly 
affected  uterine  or  pelvic  veins  ;  sometimes,  however,  no 
evidence  of  pelvic  phlebitis  can  be  obtained  clinically.  But 
the  condition  is  almost  certainly  septic  in  all  cases,  and  strep- 
tococci have  been  found  in  the  femoral  clot  by  Widal. 
Probably  these  organisms,  circulating  in  the  blood  stream, 
may  set  up  phlebitis  in  a  remote  part,  by  attacking  the 
endothelium  of  the  vein- wall.  Slight  cases  of  this  variety, 
in  which  only  the  foot  and  leg  are  affected,  are  not  un- 
common. 

Lymphatic  Form. — In  some  cases  no  signs  of  femoral 
thrombosis  can  be  found  ;  the  swollen  limb  has  a  tense,  white, 
glistening  appearance,  and  does  not  pit  on  pressure  ;  there 
may  be  enlarged  and  tender  lymphatic  glands  felt  in  the 
groin.  In  the  early  stages  the  skin  shows  a  slight  flush,  and 
later  on,  small  areas  of  dermatitis  or  superficial  gangrene  may 
appear.  It  is  stated  that  in  such  cases  the  effused  fluid  in 
the  limb  is  not  serum  (as  in  oedema),  but  coagulable  lymph. 
It  is  much  rarer  than  the  thrombotic  form,  and  is  probably 
due  to  lymphatic  infection  setting  up  a  deep  cellulitis  in  the 
affected  limb.     It  is,  of  course,  septic  in  nature. 

It  is  not  at  all  infrequent  for  cases  to  be  met  with  in 
which  both  factors,  thrombosis  and  lymphatic  infection, 
occur,  giving  rise  to  swelling  of  atypical  characters. 

Although  sepsis  must  be  regarded  as  the  essential  cause 
of  phlegmasia,  certain  contributory  causes  must  also  be 
recognised  ;  of  these  the  most  important  is  haemorrhage 
during  or  after  labour  ;  others  are  multiparity  and  general 
ill-health,  especially  blood  diseases.  The  frequency  of  phleg- 
masia has  greatly  diminished  since  the  general  adoption 
of  antiseptic  principles  in  the  practice  of  midwifery. 

Clinical  Features. — A  more  or  less  acute  onset  is  charac- 
teristic of  this  affection.  It  occurs  in  the  great  majority  of 
cases  in  the  latter  half  of  the  second  week  of  the  puerperium 
(tenth  to  fourteenth  day),  although  it  may  appear  as  early  as 
the  sixth  or  as  late  as  the  thirtieth  day.  Acute  pain  is  felt 
in  the  affected  limb,  and  the  temperature  may  rise  rapidly  to 
102°  or  104°  F.  ;  slight  shivering  or  sometimes  a  well-marked 


600  THE   PUERPERIUM 

rigor  raay  accompany  these  symptoms.  There  has  often 
been  a  certain  amount  of  pyrexia  during  the  first  puerperal 
week,  as  is  the  case  with  the  local  pelvic  inflammations — i.e. 
asepsis  has  not  been  successfully  maintained  (Fig.  275).  The 
acute  pain  and  the  fever  last  from  three  or  four  days  in  a 
mild  case;  to  ten  or  twelve  days  in  a  severe  one  ;  then  both 
subside  concurrently.  In  the  thrombotic  form,  tenderness 
and  induration  will  be  found  along  the  line  of  the  femoral 
vein.  The  affected  limb  is  immobile  as  if  from  paralysis,  and 
frequently  the  presence  of  fluid  can  be  detected  in  the  knee- 
joint.  The  temperature  of  the  affected  limb  is  about  half 
a  degree  higher  than  that  of  the  sound  one.  The  left  leg  is 
much  more  commonly  affected  than  the  right  ;  this  is  no 
doubt  due  to  the  preponderating  frequency  of  the  first  posi- 
tion of  the  vertex,  which  makes  cervical  laceration  much 
more  common  on  the  left  than  on  the  right  side,  and  pre- 
disposes to  infection  of  the  left  broad  ligament,  its  vessels 
and  lymphatics.  Both  Kmbs  are  affected  in  about  one-third 
of  the  cases,  but  almost  always  consecutively  after  an  interval 
of  one  or  two  weeks,  a  simultaneous  onset  of  the  disease  in 
both  limbs  being  extremely  rare.  From  recent  statistics  it 
appears  that  phlegmasia  occurs  about  once  in  four  hundred 
cases  of  labour.  Cases  in  which  the  upper  limb  becomes 
affected  are  very  uncommon. 

Treatment. — Treatment  should  be  chiefly  directed  to  the 
immobihsation  of  the  affected  limb,  and  the  rehef  of  the 
local  pain.  Almost  the  only  risk  attending  the  disease  is 
pulmonary  embolism  from  detachment  of  a  portion  of  blood- 
clot  from  the  thrombosed  vein.  To  prevent  the  occurrence 
of  this  accident  the  Umb  should  be  slung  in  a  cradle,  or  laid 
upon  pillows  and  immobihsed  by  placmg  heavy  sandbags  in 
contact  with  it  on  either  side,  from  the  hip  down  to  the  foot. 
Voluntarj^  movement  must  not  be  allowed  for  fourteen  days 
after  the  cessation  of  pain  and  all  febrile  symptoms.  Many 
weeks  or  even  months  may  elapse  before  all  the  sweUing  has 
disappeared  from  the  limb,  and  a  certain  amount  of  pain 
and  stiffness  on  movement  may  persist  for  even  longer 
periods.  Pain  is  best  relieved  by  the  application  of  moist 
heat,  in  the  form  of  hot  fomentations,  or  by  freely  paint- 
ing the  line  of  the  vein  with  tincture  of  belladonna.  After 
the  pain  has  disappeared  the  limb  must  be  kept  carefnlly 


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602  THE   PUERPERIUM 

wrapped  up  in  cotton  wool,  and  shielded  from  pressure  with 
a  '  cage.'  In  cases  of  unusually  acute  onset  attended  with 
a  rigor,  antistreptococcic  serum  may  be  employed.  The 
administration  of  citric  acid  in  ten-grain  doses  three  times 
daily  is  believed  to  retard  the  spread  of  the  clot  by 
diminishing  the  coagulability  of  the  blood.  Massage  is 
useful  in  the  later  stages  when  pain  and  swelling  persist. 

Pyaemia  is  a  form  of  septicsemic  infection  characterised 
by  extensive  thrombo-phlebitis  in  the  pelvic  veins,  lead- 
ing to  the  formation  of  multiple  infective  emboli,  from 
which  secondary  infective  foci  may  be  carried  to  the  heart, 
the  lungs,  the  abdominal  viscera,  the  joints,  the  synovial 
membranes,  etc.  The  emboli  may  consist  of  minute  portions 
of  infected  clot  which  have  become  detached,  or  of  aggrega- 
tions of  bacteria.  The  organisms  concerned  are  those  which 
may  also  be  met  with  in  septicaemia.  In  all  probability  they 
are  of  somewhat  attenuated  virulence,  as  pyaemia  is  some- 
what later  in  its  appearance,  and  also  runs  a  more  protracted 
course,  than  septicaemia. 

The  thrombo-phlebitic  changes  begin  in  the  uterine  or 
ovarian  veins,  whence  they  spread  to  the  external  and 
internal  iliac  veins,  and  ultimately  to  the  inferior  vena 
cava  ;  in  the  case  of  the  ovarian  veins  the  infection  spreads 
directly  to  the  renal  vein  on  the  left,  the  inferior  vena  cava 
on  the  right.  The  uterine  and  ihac  veins  are  found  affected 
at  autopsies  much  more  frequently  than  the  ovarian  veins. 

The  embohc  complications  which  may  occur  in  the  course 
of  pyaemia  lead  to  such  varied  conditions  as  ulcerative 
endocarditis,  multiple  pulmonary  abscesses,  hepatic  and 
splenic  abscesses,  pyehtis,  and  joint  effusions,  either  serous 
or  suppurative. 

The  records  of  autopsies  on  women  who  have  died  from 
puerperal  septic  diseases  appear  to  show  that  this  form  of 
sepsis  is  frequent,  for  thrombo-phlebitic  changes  are  evident 
in  from  30  to  50  per  cent,  of  such  cases  (Lea). 

Treatment. — The  specific  and  general  treatment  already 
described  for  cases  of  septicaemia  are  to  be  made  use  of  in 
pyaemia  also.  Within  recent  years  an  attempt  has  been 
made  to  limit  the  spread  of  venous  infection  by  surgical 
means. 

Ligature  or  Excision  of  Pelvic   Veins. — During  the  last 


PY.EMIA  603 

eight  or  nine  years  certain  cases  of  pysemia  associated  with 
pelvic  thrombo-phlebitis  have  been  treated  by  this  pro- 
cedure which  is  based  upon  the  operation  of  excision  of  the 
external  jugular  vein  for  aural  pysemia.  The  operation  is 
naturally  severe,  and  cannot  be  undertaken  with  any  hope 
of  success  except  in  the  early  stages,  while  the  general 
condition  of  the  patient  is  good  and  there  are  no  signs  of  the 
formation  of  embolic  metastases.  If  there  is  marked  oedema 
of  the  lower  extremity,  the  thrombosis  is  probably  too 
extensive  to  be  controlled  by  these  operations.  The  vessels 
may  be  exposed  either  by  an  extra-peritoneal  or  an  intra- 
peritoneal incision,  the  latter  being  preferred,  as  the  affected 
vessels  cannot  be  sufficiently  exposed  by  the  former. 
Further,  thrombotic  changes  may  be  found  in  the  vessels  of 
both  sides,  and  free  access  to  the  whole  of  the  pelvis  is  then 
required. 

A  practical  difficulty  in  the  application  of  this  operation 
is  the  question  of  diagnosis.  Recognition  of  thrombo- 
phlebitic  changes  in  the  pelvis  by  vaginal  examination  is 
by  no  means  certain,  and  these  changes  are  not  invariably 
found  in  cases  which  are  clinically  pyaemic.  And  further, 
it  is  not  practicable  in  all  cases  to  tie  off  or  remove  the 
affected  veins  owing  to  the  extent  of  vessel  involved  ;  yet 
the  extent  of  the  lesion  cannot  be  gauged  without  exposing 
the  veins  affected. 

It  is  impossible  in  the  meantime  to  estimate  the  value 
of  this  operation  ;  of  some  fifty  to  sixty  recorded  cases  the 
mortality  has  been  40  per  cent.  (Lea),  but  it  must  be  assumed 
that  many  of  these  were  acute  cases  in  which  recovery  was 
hardly  to  be  expected.  Further  experience  is  necessary 
before  it  can  be  decided  whether  or  not  this  operation  will 
prove  to  be  of  real  value. 

Inflammation  of  the  Mammary  Glands 
(Mastitis,  Mammary  Abscess) 

Unless  proper  precautions  are  observed  during  the  pro- 
cess of  suckling,  the  mammse  may  become  infected  by 
various  pathogenic  and  pyogenic  organisms  which  gain  access 
to  it  usually  through  superficial  skin-cracks,  or  sometimes, 
possibly,  through  the  ducts  which  open  upon  the  nipple. 


604  THE   PUERPERIUM 

Bacteriological  observations  show  that  bacteria  are  present 
in  human  milk  in  86  per  cent,  of  pregnant  and  91  per 
cent,  of  lying-in  women.  Some  bacteriologists  have  stated 
that  staphylococci  can  often  be  found  in  the  milk-ducts  of 
healthy  nursing  women  when  the  glands  appear  to  be  normal. 
It  seems  probable,  therefore,  that  the  importance  assigned  by 
clinical  observations  to  nipple-cracks  in  the  production  of 
mastitis  has  not  been  over-estimated  ;  for  if  these  organisms 
may  occur  in  the  milk-ducts  without  causing  inflammation, 
it  must  be  their  entrance  into  the  lymphatics  through  a 
wound  of  the  surface  which  sets  up  the  process.  The  physio- 
logical engorgement  of  the  breast  at  the  begimiing  of  lacta- 
tion, which  reaches  its  height  on  the  fourth  day,  does  not 
lead  to  mastitis  unless  infection  also  occurs  through  one  of 
the  channels  just  indicated.  The  inflammation  may  occur 
(1)  in  the  subcutaneous  cellular  tissue — usually  under  or 
near  the  areola  {pre-mammary  abscess)  ;  (2)  in  the  substance 
of  the  gland  [intra-mammary  abscess) ;  (3)  ia  the  sub-glandular 
connective  tissue  {retro-mammary  abscess)  ;  the  last-named 
variety  seldom  follows  infection  through  the  nipple,  but 
usually  results  from  empyaema,  or  disease  of  the  ribs.  The 
foci  of  infection  are  often  multiple  ;  suppuration  frequently 
but  not  invariably  occurs,  and  abscesses  sometimes  form  in 
more  than  one,  or  even  in  all  three,  of  the  localities  just 
indicated.  Mastitis  may  occur  during  pregnancy,  but  this 
is  rare  ;  in  the  puerperium  it  most  commonly  occurs  during 
the  first  two  or  three  weeks,  but  may  be  met  with  much  later 
than  this. 

The  onset  of  mastitis  is  attended  with  diffused  redness  and 
severe  pain  in  the  affected  gland,  a  rapid  rise  of  tempera- 
ture, headache,  and  other  signs  of  general  malaise  ;  then  a 
firm  and  very  tender  swelling  appears  at  some  part  of  the 
gland.  Suppuration  may  be  attended  by  rigors,  and  the 
usual  local  signs — softenmg  of  the  inflamed  area,  with  oedema 
of  the  skin,  or  redness  and  tension  if  the  abscess  is  super- 
ficial. A  pre-matrimary  abscess  sometimes  opens  spon- 
taneously upon  the  surface  or  into  a  large  milk  duct,  leading 
to  the  discharge  of  pus  through  the  nipple.  Sometimes 
both  glands  are  affected,  but  seldom  simultaneously,  the 
second  probably  becoming  directly  infected  from  the  first 
through  suckling  or  through  lack  of  surgical  cleanliness. 


MASTITIS  605 

Treatment. — The  prophylaxis  of  mammary  inflammation 
consists  in  the  proper  management  of  the  breasts  during 
pregnancy  and  suckhng,  which  has  been  already  described. 
When  nipple-cracks  are  promptly  and  thoroughly  treated, 
mastitis  very  seldom  ensues.  If,  owing  to  the  death  of  the 
child  or  for  any  other  reason,  the  mother  does  not  suckle, 
the  nipples  should  be  carefully  disinfected  in  the  manner 
described  on  p.  561,  and  the  breasts  protected  by  cotton- 
wool and  tightly  bandaged.  If  they  become  very  painful, 
the  bandage  may  be  removed  and  an  evaporating  lotion  {e.g. 
eau  de  Cologne  and  water)  employed  for  a  few  hours,  and  the 
bandage  then  re-applied.  A  saline  or  other  aperient  should 
be  given  daily  for  the  first  two  or  three  days.  Continuous 
pressure  with  the  aid  of  free  purgation  will,  as  a  rule,  quickly 
arrest  the  activity  of  the  glands.  The  local  application  of 
tincture  of  belladonna  and  the  administration  of  potassium 
iodide  are  seldom  required,  but  may  be  resorted  to  if  difficulty 
is  experienced  in  arresting  the  secretion. 

The  first  signs  of  inflammation  in  the  breasts  should 
at  once  be  met  by  the  following  measures  :  (1)  cessation  of 
suckling  from  the  affected  gland,  the  secretion  being  drawn 
off  as  required  with  a  breast-pump  ;  (2)  the  local  application 
of  moist  heat  (hot  fomentations),  or  preferably  of  cold  by  the 
use  of  Leiter's  coils,  through  which  a  stream  of  iced  water  can 
be  run  ;  (3)  purgation.  If  the  breast  is  extensively  affected, 
or  if  signs  of  suppuration  occur,  suckling  must  be  entirely 
suspended,  and  the  unaffected  gland  tightly  bandaged  under 
cotton- wool  to  secure  even  pressure.  Suckling  from  a 
suppurating  breast  must  be  strictly  forbidden,  for  the  milk 
is  probably  always  infected.  Suppurating  areas  must  be 
promptly  laid  open  when  recognised.  The  incisions  should, 
as  far  as  possible,  be  made  parallel  to  the  course  of  the  large 
milk-ducts  which  converge  upon  the  nipple.  The  abscess 
cavity  is  frequently  multilocular  and  of  irregular  shape  ; 
septa  must  be  broken  down  with  the  finger  to  ensure  efficient 
drainage  of  all  parts  of  the  cavity,  and  a  counter-opening  at 
some  dependent  part  may  be  required.  Rubber  tubes  should 
be  used  for  the  first  few  days  and  the  cavity  washed  out  daily 
with  an  antiseptic  solution — e.g.  carbolic-acid  lotion  1-60. 
Tonics  such  as  iron  and  quinine  are  always  indicated  during 
convalescence,  which  may  be  prolonged  when  the  general 


606  THE   PUERPERIUM 

liealth  is  unsatisfactory.  The  functional  adequacy  of  the 
gland  in  a  subsequent  pregnancy  as  a  rule  is  not  affected, 
for  the  amount  of  gland  tissue  destroj^ed  by  suppuration 
is  usually  small.  Sometimes,  however,  the  gland  is  so  dis- 
organised by  multiple  foci  of  suppuration  that  its  removal 
becomes  necessary. 

Puerperal  Haemorrhage  :    Secondary  Post-partum 
Haemorrhage 

Haemorrhage  may  occur  at  almost  any  period  of  the 
puerperium,  and  may  be  due  to  a  variety  of  different  con- 
ditions. In  slight  cases  it  takes  the  form  of  an  undue  amount 
of  bleeding  during  the  first  three  days,  undue  prolongation  of 
the  hsemorrhagic  stage  of  the  lochia,  or  recurrence  of  bleeding 
after  the  lochia  have  become  serous.  Such  cases  may  be 
due  {a)  to  retention  in  the  uterus  of  a  small  portion  of 
placenta  or  chorion,  or  blood-clot,  which  may  or  may  not 
become  infected  ;  (6)  to  delayed  involution  caused  by  not 
suckling,  or  by  general  ill-health  ;  (c)  to  uterine  conges- 
tion caused  by  cardiac  or  hepatic  disease,  by  backward  dis- 
placement of  the  uterus,  by  getting  up  too  soon,  or  by 
constipation. 

In  severe  cases  a  sudden  severe  haemorrhage  may  occur, 
or  there  may  be  continuous  bleeding  of  moderate  but  not, 
alarming  extent,  or  irregular  profuse  losses  of  blood.  Such 
cases  are  due  to  {a)  sudden  relaxation  of  the  uterus  in  the 
first  few  days  of  the  puerperium  from  nervous  shock  ;  (6)  to 
the  separation  of  retained  pieces  of  placenta  of  considerable 
size,  especially  if  they  become  infected  ;  (c)  to  the  formation 
of  a  placental  polypus  ;  {d)  to  puerperal  inversion  of  the 
uterus  ;  (e)  to  the  presence  of  new  growths  ui  the  uterus — 
e.g.  a  fibroid  which  has  become  infected,  or  is  being  extruded 
into  the  uterine  cavity,  carcinoma  of  the  cervix,  or  lastly 
chorionepitheHoma  (deciduoma  mahgnum). 

Severe  bleeding  may  occur  in  the  second  or  third  weeks 
of  the  puerperium  from  the  separation  of  a  piece  of  placental 
tissue.  Occasionally  cases,  almost  equally  severe,  occur  in 
which  there  is  no  evidence  of  placental  retention,  and  in 
which  no  other  local  cause  for  the  haemorrhage  can  be  found. 
In  these  cases  there  is  probably  a  deficiency  both  of  throm- 


CHORIONEPITHELIOMA  607 

botic  closure  of  the  utero-placental  vessels,  and  of  retraction 
of  the  uterine  muscle.  Cases  due  to  either  of  the  two  first- 
mentioned  causes  are  to  be  treated  in  the  same  manner  as 
cases  of  primary  post-part um  haemorrhage. 

The  clinical  association  of  chorionepithelioma  with  the 
puerperium  is  of  considerable  importance,  and  a  short 
description  of  this  disease  is  accordingly  necessary. 

Chorionepithelioma 

(Synonyms  :  Deciduoma  malignum  ;  syncytioma  malig- 
num  ;    carcinoma  syncytiale.) 

Chorionepithelioma  is  a  malignant  tumour  arising  either 
in  immediate,  or  more  or  less  remote,  connection  with  preg- 
nancy, and  situated  most  commonly,  but  not  invariably, 
in  the  uterus  ;  in  this  organ  it  forms  a  soft  hsemorrhagic 
growth  occupying,  the  usual  site  of  the  placenta — i.e.  the 
fundus  and  adjacent  portions  of  the  anterior  and  posterior 
uterine  walls  (Fig.  276).  The  primary  growth  may,  however, 
be  situated  in  the  vaginal  walls,  the  labium  ma  jus,  the 
Fallopian  tube,  or  the  ovary.  The  disease  is  characterised 
cHnically  by  the  occurrence  of  irregularly  recurrent  and  often 
violent  haemorrhages  in  the  puerperium,  following  an  abor- 
tion or,  more  rarely,  a  full-time  labour  ;  the  interval 
between  the  end  of  pregnancy  and  the  onset  of  these  symp- 
toms is,  however,  very  variable.  Other  symptoms  quickly 
appear — viz.  a  foul  discharge,  progressive  anaemia,  cachexia, 
fever,  and  sometimes  rigors.  Metastatic  growths  are  quickly 
formed,  and  in  many  cases  this  tumour  destroys  life  with 
almost  unexampled  rapidity.  After  much  discussion,  and 
many  contradictory  observations,  it  has  now  been  definitely 
proved  that  it  arises  from  the  chorionic  epithelium,  both 
layers  of  which  are  represented  in  the  specific  cellular 
elements  of  the  tumour.  It  therefore  is  clearly  of  embryonic, 
not  maternal,  origin. 

Microscopical  Characters. — The  cell  elements  which  are 
typical  of  this  tumour  are  the  following  (Fig.  277)  :  (1)  large 
irregular  multinucleated  masses  of  protoplasm  (plasmodia), 
in  which  cell  boundaries  cannot  be  recognised  ;  these  are 
derived  from  the  syncytium  ;  (2)  small  polyhedral  cells  with 
large  nuclei  lying  in  closely  packed  masses  ;  these  are  derived 


608 


THE   PUERPERIUM 


from  Langhans'  layer  ;  (3)  large  mononucleated  cells,  and 
multinucleated  giant  cells,  collected  in  masses,  or  invading 
the  stroma  of  the  uterine  tissues  ;  these  are  probably  derived 


from  both  (1)  and  (2).  In  addition  to  these  elements, 
definitely  recognisable  chorionic  viUi  are  sometimes  present, 
either  of  normal  appearance  or  ui  a  condition  of  hydatidiform 
degeneration  ;  from  these  villi  the  origm  of  the  three  varieties 
of   cells  just   described  has  been  traced  b}^   a  number   of 


CHORIONEPITHELIOMA 


609 


different  observers  (Fig.  277),  The  tumour  elements  show 
remarkable  powers  of  invasion  ;  they  attack  the  uterine 
tissues,  and  perforate  the  walls  of  the  blood-vessels  (usually 
veins),  and  thus  become  disseminated  by  the  blood-stream. 
This  accounts  for  the  unusually  rapid  formation  of  metas- 
tases.    The  tumour  tissues  themselves  contain  much  effused 


Fig.  277. — Cliorionepitlielioina :  Low  Power;  showing  the  origin  of  the 
Plasmodia  and  Cellular  Elements  from  a  Villus.     (Teacher.) 

blood  and  tend  to  undergo  rapid  necrosis  ;  the  greater  part 
of  the  growth  is  usually  found  to  consist  of  debris  of  broken- 
down  tissue  and  clot  ;  only  at  the  growing  edge  can  the 
characteristic  elements  be  found. 

The  striking  resemblance  of  the  cell  elements  of  this 
tumour  to  the  malignant  or  perforating  variety  of  hyda- 
tidiform  mole  has  been  referred  to  on  a  previous  page  ;  this 
E.M.  39 


610 


THE   PUERPERIUM 


t 


iO 


■.^,^^-.  .:e.<;?♦*\.^- 


3 


CHORIONEPITHELIOMA  611 

constitutes  one  of  the  chief  difficulties  in  the  microscopic 
diagnosis  of  chorionepithelioma. 

Clinical  Diagnosis  — Cases  of  chorionepitheHoma  follow- 
ing quickly  upon  an  abortion  have  been  frequently  mistaken 
for  saprsemia  with  retention  of  placental  tissue,  and  treated 
as  such.  Both  conditions  are  attended  with  haemorrhage,  a 
foul  uterine  discharge,  fever,  enlargement  of  the  uterus,  and 
the  presence  within  it  of  decomposing  debris  of  tissue  or 
blood-clot.  Clearing  out  the  uterus  brings  a  temporary 
improvement  in  cases  of  chorionepithelioma,  but  sooner  or 
later  the  symptoms  all  recur  with  severity,  and  the  uterus  is 
again  found  to  contain  considerable  masses  of  debris, 
although  completely  evacuated  at  the  jfirst  operation.  The 
rapid  reproduction  of  decomposing  tissue  in  the  uterus  under 
such  circumstances  is  strongly  suggestive  of  chorionepithe- 
lioma. The  ultimate  diagnosis  can  only  be  made  by  a  skilled 
microscopist,  and  in  cases  of  doubt  the  whole  of  the  tissue 
removed  from  the  uterus  should  immediately  be  placed  in 
normal  saline  solution  and  sent  to  the  pathologist  with  as 
little  delay  as  possible. 

Treatment. — Hysterectomy  is  the  only  treatment  which 
offers  any  chance  of  success.  Cases  have  been  recorded  in 
which  this  operation  has  been  successful  even  after  the  forma- 
tion of  definite  mestastases  in  distant  parts.  It  should, 
therefore,  be  advised  in  all  cases  however  advanced,  if  there 
is  a  reasonable  chance  of  the  patient  surviving  the  operative 
procedure. 

Reproductive  Insanity 

Insanity  may  occur  in  association  with  all  stages  of  the 
reproductive  process  ;  it  is  usual  to  describe  as  separate 
conditions  the  insanity  of  pregnancy,  the  insanity  of  the 
puerperium,  and  the  insanity  of  lactation.  Cases  occurring 
within  six  weeks  of  labour  are  classed  as  puerperal,  those 
occurring  later  as  cases  of  insanity  of  lactation  ;  this  distinc- 
tion is  artificial,  for  puerperal  involution  is  not  completed  at 
the  sixth  week,  and  lactation  commences  on  the  third  day. 
The  term  '  reproductive  insanity  '  may  conveniently  be 
used  to  include  all  three  of  these  varieties. 

From   the   statistics   of   the   Lunacy   Commissioners   it 

39—2 


612  THE   PUERPERIUM 

appears  that,  among  female  patients  in  this  country,  cases  of 
reproductive  insanity  form  about  7  to  8  per  cent,  of  the  whole, 
the  incidence  being  rather  greater  in  public  than  in  private 
institutions.  From  the  records  of  259  cases  of  reproductive 
insanity  from  the  Claybury  Asylum  recorded  by  Jones,  it 
appears  that  21-6  per  cent,  occurred  during  pregnancy,  40-6 
per  cent,  during  the  early  puerperium,  and  32-4  per  cent, 
later  than  the  sixth  puerperal  week.  With  regard  to  the 
causes  of  reproductive  insanity,  three  points  of  special 
interest  may  be  noted  :  (1)  about  25  per  cent,  of  all  cases  are 
said  to  occur  in  single  women,  and  in  cases  of  insanity  during 
pregnancy  this  preponderance  is  even  greater  ;  (2)  in  a 
considerable  proportion  of  cases  occurring  during  the 
puerperium  signs  of  septic  infection  are  present,  and  it  is 
possible  that  the  toxic  condition  of  the  blood  thus  induced 
may  determine  the  outbreak  in  patients  subject  to  hereditary 
or  other  predispositions  to  mental  instability  ;  (3)  the  sub- 
jects of  insanity  occurring  in  connection  with  lactation  are 
usually  debilitated  in  health  by  previous  child-bearing  or  by 
general  causes.  To  these  causes  must  be  added  in  all  cases 
the  general  personal  and  hereditary  conditions  which  favour 
the  occurrence  of  insanity.  According  to  Clouston,  the 
frequency  of  puerperal  and  lactational  insanity  is  about  1  to 
every  400  confinements. 

Insanity  in  pregnancy  and  in  connection  with  lactation  is 
usually  of  the  depressed  melanchohc  type,  and  is  associated 
with  tendencies  to  suicide  or  infanticide  ;  that  occurring  in 
the  puerperium  is  more  often  of  the  exalted,  maniacal, 
type.  In  pregnancy,  80  per  cent,  of  the  cases  occur  after  the 
fifth  month  ;  in  the  puerperium,  according  to  Rigden,  over 
90  per  cent,  occur  during  the  first  fourteen  days  ;  in  lactation, 
cases  occur  with  almost  equal  frequency  from  the  second 
month  to  the  end  of  the  second  year.  In  puerperal  cases  the 
most  important  premonitory  symptom  is  sleeplessness, 
which  is  almost  invariably  met  mth  ;  when  associated  with 
headache  and  slight  fever  it  is  of  still  greater  significance. 
The  onset  of  the  disease  is  often  an  acute  outbreak  of  mania, 
associated  mth  great  violence  and  restlessness.  Depressed 
types  of  insanity,  however,  may  also  occur  in  the  puerperium. 

The  prognosis  of  reproductive  insanity  is  better  than  that 
of  any  other  variety  of  insanity  ;  from  70  to  80  per  cent,  of 


INSANITY  613 

all  cases  are  said  to  recover.  The  premonitory  sleeplessness 
and  headache  are  best  treated  by  large  doses  of  alcohol  and 
by  hypnotic  drugs.  When  the  disease  fully  manifests  itself, 
the  patient  should  be  immediately  removed  to  an  institution 
for  treatment. 


Sudden  Death  in  the  Puerperium 

Causes  of  sudden  death  in  the  puerperium  may  be  due  to 
syncope,  coma,  or  pulmonary  embolism. 

Syncope  is,  of  course,  most  likely  to  occur  in  subjects  of 
chronic  cardiac  disease  (either  valvular  or  myocardiac),  in 
cases  of  profound  chronic  ansemia,  and  in  cases  where  profuse 
haemorrhage  has  accompanied  labour  or  followed  delivery. 
It  is  well  recognised  that  in  cases  of  mitral  stenosis  or  incom- 
petence the  danger  is  by  no  means  over  when  the  child  is 
born  ;  in  a  considerable  proportion  of  cases  which  terminate 
fatally,  cardiac  failure  occurs  in  the  first  week  of  the  puer- 
perium. In  some  rare  instances  shock  appears  to  be  the 
cause  of  the  syncope,  and  sudden  death  has  been  known  to 
follow  rapid  emptying  of  the  uterus,  as  in  precipitate  labour, 
in  apparently  healthy  persons. 

Syncope  from  cardiac  disease  can  only  be  treated  by 
cardiac  stimulation  and  the  administration  of  oxygen.  When 
following  profuse  haemorrhage  or  such  grave  accidents  as 
rupture  of  the  uterus  intravenous  saline  transfusion  should  be 
performed. 

Pulmonary  embolism  may  occur  during  pregnancy, 
labour,  or  the  puerperium.  It  may  be  caused  by  detachment 
of  a  portion  of  clot  from  a  healthy  thrombosed  uterine  sinus 
by  violent  coughing,  by  muscular  exertion,  or  during  a 
convulsion  ;  sometimes  it  appears  to  be  spontaneous. 
Pulmonary  emboli  of  this  kind  may  contain  a  portion  of  a 
chorionic  villus  which  has  entered  a  uterine  sinus  and  been 
carried  thence  to  the  lungs.  Occasionally  air  embolism  is 
caused  by  the  injection  of  air  into  the  uterus  ;  this  has  fol- 
lowed puerperal  intra-uterine  douching,  or  intra-uterine 
injections  of  glycerine  for  induction  of  premature  labour, 
when  these  procedures  have  been  clumsily  carried  out  and 
air  pumped  into  the  uterus.     Lastly,  pulmonary  embolism 


614  THE   PUERPERIUM 

may  occur  in  cases  of  phlegmasia  dolens  by  detachment  of  a 
portion  of  the  femoral  thrombus. 

Pulmonary  embolism  may  cause  instant  death,  but  this 
is  rare.  Usually  some  hours  elapse  during  which  certain 
symptoms  develoj)  which  vary  according  to  the  size  of  the 
obstructed  vessel.  If  this  is  large,  extreme  ak-hunger 
(dyspnoea),  with  cyanosis,  and  a  rapid  feeble  pulse  are  the 
chief  symptoms  ;  if  the  vessel  is  small,  the  symptoms 
resemble  those  of  shock — pallor,  cold  surface,  and  small 
feeble  pulse.  Recovery  is  not  impossible  in  the  latter  case, 
although  naturally  the  prognosis  is  very  grave. 

The  only  treatment  possible  is  cardiac  stimulation  and 
administration  of  oxygen. 

Coma  may  occur  in  the  puerperium  in  the  subjects  of 
diabetes,  in  connection  with  eclampsia,  or  from  cerebral 
hsemorrhage. 


Part  VI 

THE    NEW-BOEN    CHILD 

General  Management 

When  the  child  has  been  delivered  in  a  healthy  condition 
the  respiratory  process  is  commenced  almost  instantly,  and 
after  a  few  ineffectual  gasps  it  cries  lustily.  The  mouth  and 
throat  should  be  immediately  cleared  out  by  laying  the  child 
on  its  side  and  wiping  out  the  buccal  cavity  and  pharynx 
with«a  piece  of  wet  cotton-wool  twisted  round  the  little  finger. 
Delay  in  breathing  on  the  child's  part  may  be  overcome  by 
lightly  flicking  or  by  slapping  its  body,  or  by  sprinkling  tepid 
water  on  its  face  and  chest.  When  breathing  has  been 
started  the  eyes  should  be  wiped  with  boric  acid  lotion  (1  in 
40)  to  free  the  lids  from  vernix  caseosa,  etc.  ;  if  a  purulent 
vaginal  discharge  has  been  present  during  pregnancy,  a 
solution  of  1  in  4,000  perchloride  of  mercury  should  be  used 
for  this  purpose,  and  afterwards  1  or  2  minims  of  a  1  per  cent, 
solution  of  nitrate  of  silver  introduced  into  the  lower  eyelid 
with  a  dropper  ;  this  procedure,  introduced  by  Crede,  is  a 
reliable  prophylactic  against  ophthalmia  neonatorum  (see 
p.  646).  The  cord  may  be  divided  as  soon  as  it  has  ceased 
pulsating,  or  earlier  when  respiration  has  been  satisfactorily 
established.  Two  ligatures  of  twisted  thread,  previously 
boiled,  should  be  applied,  one  about  an  inch  and  a  half  from 
the  navel,  the  other  an  inch  further  away  ;  that  on  the  foetal 
side  must  be  tightly  tied  with  care,  and  the  cord  then  divided 
with  a  pair  of  sterilised  (boiled)  scissors.  Careful  antiseptic 
precautions  are  required  in  ligaturing  and  dividing  the  cord 
on  account  of  the  danger  of  umbilical  sepsis. 

The  infant's  bath  is  usually  undertaken  by  the  nurse,  but 
the  medical  man  must  see  that  the  work  is  properly  done. 
The  amount  of  vernix  caseosa  varies  greatly  ;  when  there  is 
a  good  deal  it  can  best  be  removed  by  the  use  of  warm  olive 


616  THE   NEW-BORN   CHILD 

oil  and  swabs  of  cotton-wool.  Unless  all  vernix  is  removed 
from  the  folds  of  the  skin  at  the  groins  and  axillae,  cutaneous 
irritation  will  afterwards  be  caused.  The  infant  may  then 
be  placed  in  a  bath  of  soap  and  water  at  a  temperature  of 
100°  F.  The  medical  man  must  afterwards  examine  the 
child's  body  and  make  sure  that  no  congenital  defect  is 
present,  such  as  cleft  palate  (which  would  hinder  suckling), 
hernia,  undescended  testicle,  or  imperforate  anus  ;  the 
immediate  recognition  of  the  latter  defect  is  a  very  important 
matter,  both  for  the  credit  of  the  doctor  and  the  chances  of 
survival  of  the  child.  In  the  case  of  a  difficult  labour,  the 
possibility  of  obstetric  injuries  to  the  head  or  limbs  must  be 
borne  in  mind.  Occasionally  an  infant  is  born  with  one  or 
two  teeth  already  erupted  :  they  are  usually  central  lower 
incisors.  The  position  of  the  caput  in  head  presentations 
may  be  noted  for  confirmation  of  the  clinical  diagnosis  of 
position.  It  must,  however,  be  borne  in  mind  thal^  the 
position  of  the  caput  tends  to  change  after  birth  by  gravity  : 
thus  if  the  child  is  laid  upon  its  side  the  fluid  in  the  caput 
tends  to  gravitate  to  the  dependent  part  of  the  scalp. 
The  stump  of  the  cord  should  be  examined  to  make  sure 
that  the  ligature  is  secure,  the  cut  surface  painted  with 
tincture  of  iodine,  and  a  sterilised  dressing  applied  so  as  to 
envelop  it  ;  or  the  cord  may  first  be  dusted  over  with  pow- 
dered boric  acid,  and  then  enclosed  in  boric  lint.  The 
scorched  linen  rag  which  is  popularly  employed  in  many 
parts  of  the  country  for  this  purpose  is  a  very  fair  approach  to 
a  sterihsed  dressing.  The  nurse  must  take  the  greatest  care 
to  keep  the  cord  surgically  clean  during  the  process  of  shed- 
ding. The  child  should,  if  possible,  be  weighed  before  being 
dressed,  and  it  is  well  to  keejD  a  regular  record  of  its  tempera- 
ture, taken  in  the  fold  of  the  groin. 

It  is  of  great  importance  that  the  new-born  infant  should 
be  carefully  protected  from  cold  ;  weakly  infants  are 
especially  susceptible  to  chill,  the  results  of  which  are  often 
serious.  It  should  therefore  be  kept  weU  wrapped  ujj  in 
a  cot  warmed  with  hot-water  bottles  ;  the  water  used  to  fiU 
the  bottles  must  not  be  more  than  warm,  and  they  must  be 
placed  underneath  the  blankets  on  which  it  lies,  as  burning 
is  very  readily  caused  by  comparatively  low  degrees  of  heat  in 
young  infants.     During  the  first  twenty-four  hours  the  child 


BREAST  FEEDING  617 

sleeps  almost  continuously,  and  should  be  allowed  to  lie  quietly 
in  its  cot.  It  may  be  put  to  the  breast  twice  on  the  first  day, 
•  and  three  or  four  times  on  the  second,  for  not  longer  than  ten 
minutes  ;  a  little  secretion  is  in  this  way  obtained.  In 
addition,  it  may  be  given  a  teaspoonful  of  boiled  water  every 
three  or  four  hours  ;  this  will  usually  be  readily  taken, 
and  serves  to  promote  the  estabhshment  of  the  renal 
secretion.  If  the  child  is  to  be  nursed,  no  other  food  should 
be  given  besides  what  is  obtained  from  the  breasts  except  in 
the  case  of  premature  infants  (see  p.  628).  Meconium  is 
usually  passed  freely  during  the  first  two  days  ;  this  con- 
sists of  a  viscid,  dark  greenish-black  odourless  material. 
The  amount  voided  is  considerable,  and  for  the  first  two 
days  the  stools  consist  of  this  material  alone.  The  urine 
passed  during  the  first  few  days  is  usually  scanty,  distinctly 
yellowish  in  colour,  and  not  infrequently  it  leaves  a 
deposit  of  pink  urates  on  the  diaper.  It  nearly  always 
contains  a  trace  of  albumen. 

Breast  Feeding. — The  proper  food  for  the  new-born  child 
is  its  mother's  milk  ;  unless  definite  and  valid  reasons  exist 
for  feeding  it  in  some  other  manner,  every  child  should  be 
suckled  by  its  mother  for  the  first  three  to  six  months  of  its 
life.  This  is  best  for  the  infant  because  it  is  receiving  a 
natural  food  suited  to  its  special  requirements,  and  best  for 
the  mother  because  a  period  of  mammary  activity  is  a  valu- 
able aid  to  the  processes  of  involution  in  the  genital  tract. 
It  must,  however,  be  recollected  that  cases  occur  occasionally 
in  which  breast  milk  is  abnormal  in  composition,  the  element 
most  often  deficient  bemg  sugar.  In  such  cases  the  infant 
will  not  thrive  on  the  breast.  Other  instances  sometimes 
occur  in  which  apparently  normal  breast  milk  disagrees,  and 
leads  to  severe  digestive  disturbances,  which  at  once  yield 
when  an  artificial  food  is  substituted  for  it. 

Contra-indications  for  Suckling. — These  may  be  briefly 
stated,  and  require  little  or  no  comment  : 

General.     (1)  Pulmonary  tuberculosis  in  all  stages. 

(2)  Valvular  lesions  of  the  heart  with  incom- 

plete compensation. 

(3)  Syphilis. 

(4)  Acute  illness  of  any  kind. 


618 


THE   NEW-BORN  CHILD 


Local.         (1)  Severe  fissures  of  the  nipple. 

(2)  Acute  mastitis,  with  or  without  suppura- 

tion. 

(3)  Absence  or  marked  deficiency  of  secretion. 

(4)  Incurable  retraction  of  the  nipples. 

Infantile.   (1)  Inability  to  suck  from  feebleness  or  from 
cleft  palate. 

Composition  and  Characters  of  Human  Milk.— The  reac- 
tion of  human  milk  is  alkaline,  but  on  exposure  to  the  air  it 
rapidly  changes  by  lactic-acid  fermentation,  becoming  first 
neutral  and  finally  acid.  Its  specific  gravity  varies  between 
1030  and  1034,  and  it  contains  about  88  per  cent,  of  water. 
In  solution  are  found  sugar  (lactose),  certain  nitrogenous 
substances  (casein  and  a  small  proportion  of  lactalbumen,  or 
whey  proteid),  inorganic  salts  (chloride  of  sodium,  phosphates 
of  lime,  sodium,  potassium,  and  magnesium),  and  traces  of 
free  gases  (carbonic  acid,  oxygen,  nitrogen).  These  various 
constituents  are  constantly  present,  but  their  proportions 
vary  at  different  periods  of  the  puerperium.  The  following 
table  has  been  compiled  by  Cameron  and  Soldner  from  a 
recent  series  of  observations,  and  their  results  have  been 
generally  confirmed  by  others  : 


Period. 

Proteids. 

Fat. 

Svigar. 

Mineral  Salts. 

1st  week 
2n(i    ,, 
4th    „ 
3rd  month     . 

2-0% 
1-6% 
M% 
1-0% 

2-8% 

3-1% 
3-8% 
2-9% 

5-4% 
6-2% 
6-4% 
6-7% 

0-34% 

0-27% 
0-22% 
0-20% 

An  analysis  of  94  samples  of  human  milk  by  Carter  and 
Richmond,  taken  at  varying  periods  of  the  first  month  of  the 
puerperium,  gives  the  following  arithmetical  mean  : 


Specific  gravitj^ 

.     1030  to  1031 

Water      .... 

88-04 

Proteid    .... 

1-97 

Fat 

307 

Sugar       .... 

6-59 

Ash  (salts) 

0-26 

It  will  thus  be  seen  that  the  secretion  of  the  first  week 
contains  the  largest  proportion  of  proteids  and  salts  ;    after 


HUMAN   MILK  619 

this  period  the  proportions  of  these  constituents  steadily 
diminish.  Fat  is  found  to  increase  up  to  the  end  of  the  first 
month,  and  then  to  fall  considerably  ;  sugar  steadily 
increases  in  proportion  to  the  end  of  the  third  month.  The 
average  ratio  of  proteids  to  carbohydrates  (sugar  and  fat 
combined)  is  1  to  3|.  Human  milk  is  to  be  regarded  as  a 
food  of  somewhat  variable  composition,  and  it  is  probable 
that  a  corresponding  variation  exists  in  the  nutritional 
requirements  or  the  digestive  capacities  of  infants.  The 
mammary  secretion  of  a  multipara  is  believed  to  be  less 
variable  in  amount  and  constitution  than  that  of  a  primi- 
para.  Slight  variation  in  the  proportion  of  proteid,  fat,  and 
sugar  in  human  milk  appears  to  exert  little  influence  upon 
the  progress  of  the  child. 

The  daily  amount  secreted  by  the  mammary  glands  is 
estimated  at  from  1,000  to  1,200  grammes.  This  figure  has 
been  arrived  at  from  estimating  the  amounts  withdrawn 
from  the  breasts  by  the  infant  at  its  feeds  {vide  infra, 
Test-Feeds).  The  presence  of  micro-organisms  in  the  milk 
of  healthy  women  has  been  already  mentioned. 

Diet  is  an  important  factor  in  maintaining  the  process  of 
lactation  ;  food  rich  in  proteids  and  carbohydrates,  but 
simple  in  form,  and  accompanied  by  a  liberal  allowance  of 
fluid,  is  best  for  a  nursing  woman.  In  such  a  diet  milk  will 
obviously  form  an  important  item.  Alcohol  is  not  necessary. 
Fruit  and  green  vegetables  must  be  taken  with  caution,  as 
they  frequently  affect  the  milk  and  cause  digestive  dis- 
turbances in  the  child.  The  greater  number  of  purgative 
drugs  also  find  their  way  into  the  lacteal  secretion  and  act 
upon  the  child,  castor  oil  being  the  chief  exception.  The 
quality  of  the  lacteal  secretion  may  be  injuriously  affected 
by  nervous  shock,  emotion,  fits  of  anger,  hysteria,  and  other 
nervous  disturbances,  but  we  have  no  precise  knowledge  of 
the  nature  of  the  changes  which  occur  in  it.  From  this  it 
follows  that  women  of  a  pronounced  emotional  temperament 
do  not  make  good  nurses.  When  menstruation  occurs  in 
nursing  women,  the  monthly  period  is  accompanied  by  a 
diminution  in  the  total  amount  of  the  mammary  secretion 
and  an  increase  in  the  proportion  of  solids.  The  effect  of  the 
occurrence  of  pregnancy  is  variable,  and  often  no  influence  at 
all  appears  to  be  exerted  by  it  on  the  mammary  function. 


620  THE   NEW-BORN   CHILD 

When  suckling  by  the  mother  is  impracticable  from  the 
first,  or  has  to  be  prematurely  abandoned,  the  infant  may  be 
brought  up  by  artificial  feeding  or  by  a  wet-nurse. 

Growth  and  Progress  of  the  Child. — The  only  true  test 
of  successful  feeding  is  the  condition  of  the  child.  During  the 
first  three  days  it  loses  weight  owing  to  the  evacuation  of 
the  meconium  and  to  loss  of  fluid  through  the  kidneys  and 
the  lungs  ;  this  loss  seldom  exceeds  5  or  6  ounces,  but  in  the 
child  of  a  primipara  loss  of  weight  may  continue  up  to  the 
fifth  or  sixth  day  owing  to  tardy  establishment  of  full  mam- 
mary activity.  The  larger  the  infant  the  greater  is  the  abso- 
lute loss  of  weight  which  occurs.  At  the  end  of  the  first  week 
the  loss  ought  to  have  been  made  up  and  the  weight  at 
birth  regained,  but  it  is  not  uncommon  for  progress  to  be 
slower  than  this.  During  the  remainder  of  the  first  month 
a  gain  of  4  to  7  ounces  a  week  is  satisfactory. 

xA.ttempts  have  been  made  to  check  the  progress  of  the 
child  by  means  of  test-feeds,  i.e.,  the  infant  is  carefully 
weighed  upon  delicate  scales  immediately  before  and  imme- 
diately after  suckling.  Observations  upon  series  of  cases 
have  shown  that  the  amount  of  milk  taken  from  the  breast 
by  the  same  infant  at  different  meals  varies  to  a  remarkable 
extent,  the  difference  being  as  great  as  1  to  7  or  1  to  8. 
And,  further,  infants  of  approximately  the  same  age  and 
weight  do  not  consume  the  same  quantity  of  milk  in  twenty- 
four  hours.  The  large  amomits  occasionally  taken  from  the 
breast  by  young  infants  without  injury  tend  to  show  that 
the  capacity  of  the  stomach  increases  more  rapidly  than 
was  supposed.  Calculations  of  the  daily  total  made  from 
a  single  test-feed  are  quite  unreliable  (Forsjiih). 

About  the  third  or  fourth  day  the  character  of  the  infant's 
motions  begins  to  alter ;  the  meconium  disappears,  and  fsecal 
matter,  yellow  in  colour,  alkaline  in  reaction,  and  of  the  con- 
sistence of  custard,  takes  its  place.  Three  or  four  motions  are 
usually  passed  daily.  Digestive  disturbances  immediately 
affect  their  character  (see  p.  631).  The  umbilical  cord  should 
undergo  dry  aseptic  necrosis  ;  a  line  of  demarcation  forms  at 
its  junction  with  the  abdominal  wall,  and  about  the  fifth  or 
sixth  day,  under  normal  conditions,  it  separates  spontane- 
ously, leaving  a  small  clean  ulcer,  which  cicatrises  rapidly. 
It  is,  however,  not  very  uncommon  for  the  root  of  the  cord 


ARTIFICIAL   FEEDING 


621 


to  undergo  a  moist  form  of  necrosis  without  offensive  odour, 
and  under  these  circumstances  separation  may  be  delayed 
until  the  second  or  even  the  third  week.  A  cord  in  this  con- 
dition must  be  treated  with  the  most  scrupulous  care,  and 
kept  covered  with  boric  acid  or  some  other  non-irritating 
antiseptic  such  as  aristol.  The  skin  of  a  healthy  infant  often 
desquamates  during  the  first  week.  Towards  the  third  or 
fourth  day  the  skin  becomes  of  a  yellowish  tinge,  and  in  some 
cases  the  conjunctiva  becomes  similarly  coloured.  This  is 
the  result  of  a  physiological  process  of  haemolysis  occurring 
in  the  liver,  and  is  not  a  true  jaundice,  the  pigment  being 
derived  from  the  blood,  not  from  the  biliary  secretion.  It 
passes  off  in  a  few  days,  and  is  not  associated  with  any 
unfavourable  symptoms. 

Artificial  Feeding. — ^Two  substitutes  for  human  milk 
may  be  employed — viz.,  the  milk  of  the  cow  and  the  ass  ;  the 
comparative  composition  of  these  three  is  shown  in  the 
following  table  (Rotch)  : 


— 

Human  Milk. 

Cow's  Milk. 

Ass's  Milk. 

Sp.  G.       .         .         . 

1028  to  34 

1032 

1030 

Proteid 

1  to  2     % 

3-5% 

2-2% 

Fat   .... 

3  „  4     % 

4-0% 

1-6% 

Sugar 

6  „  7     % 

4-5% 

6-1% 

Salts 

0-1   „   0-2% 

0-7% 

0-5% 

During  recent  years  an  elaborate  study  has  been  made  of 
the  composition  of  cow's  milk  and  the  variations  which  it 
undergoes.  It  has  been  found  that,  while  the  average  com- 
position is  as  stated  in  the  table,  wide  variations  occur  in  the 
milk  of  different  kinds  of  cows,  and  also  in  the  milk  of  any 
single  animal  from  day  to  day.  By  using  the  mixed  milk  of 
a  herd,  greater  uniformity  of  composition  can  be  obtained 
than  with  the  milk  of  a  single  animal.  This  is  directly  the 
contrary  of  what  was  formerly  believed  to  be  the  case.  We 
have  seen  that  human  milk  is  also  subject  to  considerable 
variations  in  composition ;  according  to  Rotch,  this  is 
especially  the  case  with  the  proteids,  which  may  vary  from 
'  1-08  per  cent,  to  4-14  per  cent,  without  producing  any  ill 
effect  upon  the  child.  It  will  accordingly  be  understood  that 
the  above  table  sets  forth  the  average  proportions  only. 


622  THE   NEW-BORN   CHILD 

It  may  be  said  generally  that  cow's  milk  differs  from 
human  milk  in  being  acid  in  reaction,  in  containing  con- 
siderably less  sugar  and  considerably  more  proteid,  while 
the  percentage  of  fat  is  about  the  same  ;  further,  the  proteids 
of  cow's  milk  differ  in  being  less  easily  digestible  than  those 
of  human  milk.  Milk  proteids  are  of  two  kinds  :  caseinogen 
or  coagulable  proteid — i.e.,  coagulable  by  the  enzyme  of 
rennet,  and  ivJiey  proteids  or  non-coagulable  proteids — i.e., 
those  Avhich  remain  in  solution  after  treatment  with  rennet. 
The  percentage  amounts,  according  to  Koenig,  are  : 

Human.  Cow. 

Caseinogen 0-59%  2-88% 

Whey  proteid  ....   1-23%  0-53% 

The  practical  result  of  this  difference  is  that  the  curd  of  cow's 
milk  is  coarser  and  more  difficult  to  digest  than  that  of 
human  milk. 

It  must  also  be  borne  in  mind  that  cow's  milk  is  liable 
to  contamination  with  pathogenic  organisms,  and  certain 
epidemic  diseases,  such  as  scarlet  fever  and  diphtheria,  may 
be  proj^agated  by  it.  From  the  use  of  such  preservatives  as 
boric  acid,  which  are  often  added  to  milk  in  hot  weather  in 
order  to  prevent  the  occurrence  of  fermentation,  acute  gastro- 
intestinal irritation  may  be  set  up.  And,  further,  tuber- 
culous disease  is  not  uncommon  in  cows,  sometimes  affecting 
the  udders,  but  more  often  the  respiratory  system.  The 
milk  of  animals  thus  affected  contains  active  tubercle 
bacilli,  by  which  the  disease  may  be  set  up  in  the  infants  to 
whom  it  is  given.  Eermentation  may  occur  in  cow's  milk, 
rendering  it  extremely  irritating  to  the  gastro-intestinal 
mucous  membranes. 

Ass's  milk  more  closely  resembles  human  mUk  in  com- 
position, not  only  as  regards  the  proportions  of  its  elements, 
but  also,  it  is  believed,  in  the  digestibility  of  its  proteids. 
The  amount  of  fat  is,  however,  much  less  than  in  human  milk. 
The  remarks  made  as  to  the  contamination  of  cow's  milk 
apply  equally  to  ass's  milk.  The  practical  objection  to  the 
use  of  ass's  milk  is  that  it  cannot  be  obtained  except  in  large 
towns,  and  its  cost  is  prohibitive  to  all  but  the  rich.  Accord- 
ingly the  staple  substitute  for  human  milk  is  cow's  milk. 

The  preparation  of  cow's  milk  for  infant  feeding  is  a 
matter    of    the    highest    practical    importance  ;     the  two 


ARTIFICIAL   FEEDING  623 

important  steps  are  sterilisation,  and  modification  in 
composition. 

Sterilisation. — The  simplest  way  to  sterilise  milk  is  to  boil 
it  for  ten  minutes  ;  the  boiling-point  of  milk  is  220°  F.  This 
destroys  all  bacteria,  including  their  spores.  The  objections 
to  boiling  are  (1)  that  it  impairs  the  flavour  of  the  milk  ; 
(2)  that  it  destroys  certain  elements,  of  unknown  com- 
position, upon  which  its  antiscorbutic  properties  depend. 
Constipation,  scurvy,  and  rickets  are  believed  to  be  produced 
by  its  prolonged  use.  Boiling  is  therefore  not  to  be  advised. 
The  second  method  is  to  place  the  milk  to  be  sterilised  in  a 
water-bath,  raise  the  water  to  the  boiling-point,  maintain  it 
at  this  temperature  for  twenty  minutes,  and  then  remove  the 
vessel  containing  the  milk  and  allow  it  to  cool.  If  the  milk- 
containing  vessel  is  only  three-fourths  immersed  in  the 
boiling  water  the  temperature  of  the  milk  does  not  rise  much 
above  180°  F.  This  method  is  often  spoken  of  as  '  sterilisa- 
tion.' A  third  method  is  to  employ  a  water-bath  in  the  same 
manner,  but  to  raise  the  temperature  of  the  water  only  to 
170° — 175°  F.,  and  maintain  it  at  that  temperature  for  thirty 
to  forty  minutes.  The  temperature  of  the  milk  will  be  about 
160°  F.  This  is  often  called  '  Pasteurisation.'  '  Sterilisa- 
tion,' so-called,  destroys  practically  all  germs  except  the 
anthrax  bacillus,  but  does  not  destroy  their  spores.  '  Pas- 
teurisation '  produces  much  the  same  result,  and  if  repeated 
two  or  three  times,  milk  may  be  rendered  absolutely  sterile 
in  this  manner.  Unknown  chemical  changes  are  induced  in 
milk  by  heat,  and  it  is  therefore  desirable  to  employ  the 
method  in  which  the  temperature  used  is  the  lowest. 

Experience  of  the  use  of  sterilised  milk  has  shown  that  it 
loses  some  of  its  nutritive  value  in  the  process. 

If  a  fresh  and  uncontaminated  supply  of  milk  can  be 
obtained,  this  is  preferable  to  any  method  of  sterilisation, 
but  it  is  agreed  that  the  ordinary  milk  supply  of  most  towns 
absolutely  requires  to  be  sterilised. 

Modification. — The  composition  of  cow's  milk  can  be 
approximated  to  that  of  human  milk  in  respect  of  the 
proportions  of  the  principal  ingredients.  First  the  milk  is 
diluted  to  reduce  the  percentage  of  proteids  to  about  one- 
third  ;  this  will  be  done  by  adding  two  parts  of  diluent  to 
one  of  milk.     But  this  procedure  will  reduce  the  proportions 


624  THE   NEW-BORN   CHILD 

of  fat  and  sugar  to  a  point  much  below  their  level  in  human 
milk  ;  therefore  fat  in  the  form  of  cream,  and  sugar  in  the 
form  of  lactose,  are  added  to  the  diluted  milk  in  order  to 
bring  up  their  proportions  to  the  proper  level.  Thus,  if 
one  part  of  milk  is  diluted  with  two  parts  of  water,  the  pro- 
teid  in  the  mixture  will  be  about  1|  per  cent.  ;  this  is  a  little 
too  low,  but  it  must  be  recollected  that  the  proteids  of  cow's 
milk  are  less  easily  digested  than  those  of  human  milk. 
Cream  as  sold  at  dairies  varies  in  the  percentage  of  fat  which 
it  contains  from  10  per  cent,  to  20  per  cent.  ;  when  in  the 
case  of  delicate  children  accurac}^  is  desirable,  the  fat  may  be 
estimated  at  a  laboratory.  A  sufficiently  exact  10  per  cent, 
cream  can  be  prepared  domestically  by  allowing  a  quart 
of  fresh  whole  milk  to  stand  in  a  quart  measure  for  six 
hours  :  the  upper  eight  ounces  will  consist  of  10  per  cent, 
cream  ;  or,  if  more  exact  proportions  are  desirable,  a  sepa- 
rated (centrifugalised)  standardised  cream  of  16  per  cent, 
can  be  obtained  from  most  of  the  large  dairies.  By  dilution 
of  one  to  two,  the  proportion  of  sugar  in  milk  is  reduced  to 
about  one-fourth  of  the  required  amount.  A  little  is  replaced 
by  the  added  cream  ;  the  remainder  can  be  made  up  with 
lactose. 

Although  the  proportions  of  the  chief  ingredients  can  be 
thus  adjusted,  certain  differences  will  remain — viz.,  the  acid 
reaction,  and  the  comparatively  high  percentage  of  casein- 
ogen  (coagulable  proteid).  The  reaction  can  be  adjusted  by 
using  lime-water  as  a  portion  of  the  diluent  ;  the  digesti- 
bility of  the  proteids  can  be  increased  by  the  use  of  citrate 
of  sodium  in  doses  of  one  grain  to  each  ounce  of  the  prepared 
food.  This  salt  possesses  the  useful  property  of  retarding 
the  coagulation  of  all  forms  of  albumen. 

A  modified  milk  suitable  for  the  first  week  of  infant  life 
may  therefore  be  made  up  as  follows  : 


Whole  milk 

.     5  oz. 

Water         .... 

.  13  oz. 

Lime-water 

.     li  oz. 

Cream  (10%)      . 

.     2|  drs. 

Lactose       .... 

.     2  tablespoonfuls 

Citrate  of  soda   . 

.  20  grs. 

The  pint  of  food  thus  prepared  is  sterilised  before  use  by 
one  or  other  of  the  methods  just  described.     The  most  con- 


ARTIFICIAL   FEEDING 


625 


venient  apparatus  is  that  of  Soxhlet  (Fig.  279).  During  its 
first  week  of  life  the  infant  requires  about  ten  feeds  in  twenty- 
four  hours.  Into  each  of  the  ten  bottles  provided  sufficient 
of  the  feeding  mixture  is  poured  to  make  one  feed.  All  the 
bottles  are  simultaneously  heated  in  the  water-bath  to  the 
temperature  desired  and  their  mouths  closed  with  the  special 
rubber  cap  supplied.  They  are  then  removed,  and  as  the 
contents  of  the  bottles  cool  the  rubber  caps  become  drawn  in 
by  atmospheric  pressure,  rendering  them  practically  air- 
tight. Thus  the  day's  supply  is  prepared  without  undue 
trouble. 

The  amount  for  each  feed  during  the  first  week  is  1|  ounce. 
At  the  beginning  of  the  second  week  the  amount  is  increased 


Fig.  279. — Soxhlet's  Milk  Steriliser. 


to  2  ounces.  The  feeds  should  be  given  every  two  hours  in 
the  day,  and  every  three  to  four  hours  at  night ;  after  the 
fourth  week  2|  ounces  can  be  given  at  each  feed.  The 
degree  of  concentration  should  be  gradually  raised  thus  : 
third  week,  milk  6|,  diluent  13|  ;  fourth  week,  milk  8, 
diluent  12  ;  sixth  week,  milk  9,  diluent  11  ;  eighth  week, 
milk  10,  diluent  10  (in  20  ounces).  Whole  milk  can  generally 
be  given  to  an  infant  three  months  old. 

A  bottle,  with  a  large  rubber  teat  and  without  tubing, 
should  be  employed  ;  after  use,  the  bottle  and  the  rubber 
teat  should  both  be  boiled  for  ten  minutes,  and  kept  immersed 
in  boric  acid  lotion  until  again  required.  The  infant's  mouth 
should  receive  the  same  attention  as  in  breast  feeding. 

Healthy  infants  with  normal  digestive  capacity  almost 
invariably  thrive  upon  this  method  of  feeding.  Sometimes 
E.M.  40 


626 


THE   NEW-BORN   CHILD 


infants  are  unable  properly  to  digest  cow's  milk,  and  some 
further  modification  is  then  required.  When  the  infant  is  not 
properly  digesting  its  food  the  stools,  instead  of  being  of  the 
smooth,  uniform  consistence  of  custard,  become  more  or  less 
granular  or  even  lump}^  and  frequently,  from  fermentation, 
they  become  green  in  colour  and  acid  in  reaction.  Looseness 
or  diarrhoea  usually  accompanies  these  changes,  but  some- 
times there  is  constij)ation.  The  infant  is  restless,  or  some- 
times cries  after  feeding,  instead  of  falling  asleep  as  is  the  case 
in  health.  Colicky  abdominal  pains  often  occur,  indicated 
by  loud  crying  or  screammg,  in  which  the  legs  are  firmly 
flexed  on  the  abdomen  ;  often  the  s]3asm  of  pain  is  relieved 
by  the  escape  of  a  little  flatus.  At  the  same  time  the  infant 
gains  little  weight,  or  may  actually  lose  weight.  Under  ' 
such  circumstances  cow's  milk  diluted  and  modified  in  the 
manner  above  described,  and  then  peptonised  for  periods 
varying  from  ten  to  thirty  minutes,  may  be  used  ;  or  the 
preparation  sold  as  '  humanised  '  milk  may  be  substituted 
for  it.  This  preparation  is  easily  digested  ;  however,  hifants 
gain  in  weight  but  slowly  upon  it,  and  its  use  for  prolonged 
periods  is  undeshable.  In  severe  cases  a  very  useful  sub- 
stitute for  milk  may  be  found  hi  a  mixture  of  whey  and 
cream,  usually  called  the  '  whey-cream  mixture.'  Whey 
differs  from  whole  milk  in  bemg  almost  entirely  free  from  the 
coagulable  proteids,  and  in  containing  but  a  small  percentage 
of  fat.  The  composition  of  whey,  according  to  Koenig,  is  as 
foUows  : 


Proteid    '      . 

.     0-86% 

Salts  . 

.       0-63% 

Fat 

.     0-32% 

^Vater 

.     93-38% 

Sugar   . 

.     4-90% 

The  proteid  elements  which  are  most  difficult  to  digest 
having  been  ehminated,  this  food  is  very  suitable  for  pre- 
mature or  delicate  infants,  and  may  be  given  in  the  propor- 
tions of  whey  5iss.,  cream  5J.  for  each  feed.  The  mixture 
must  of  course  be  sterihsed. 

In  America  a  system  of  modif3"mg  cow's  milk  by  labora- 
tory processes,  so  that  the  various  ingredients  may  be  com- 
bined in  any  required  proportions  {humanised  millc),  has 
been  widely  adopted,  and  it  is  customary  for  the  phj^sician 
to  prescribe  the  exact  composition  of  the  milk  he  orders,  and 


MIXED   FEEDING  627 

vary  it  from  week  to  week  as  he  raay  think  desirable.  Such 
methods  can  only  be  employed  by  specialists,  but  a  prepara- 
tion known  as  '  humanised  milk  '  can  be  obtained  from  the 
principal  dairies,  which  will  be  found  more  readily  digestible 
than  ordinary  cow's  milk,  although  its  exact  composition 
and  mode  of  preparation  are  not  known.  Swiss  condensed 
milk  may  be  used  as  an  alternative  to  sterilised  cow's  milk  ; 
in  the  first  week  the  dilution  should  be  1  to  16,  rising  to 
1  to  12  for  the  remainder  of  the  first  month.  The  addition 
of  sugar  is  unnecessary.  Dried  milk  prepared  by  rapid 
evaporation,  such  as  '  Glaxo,'  forms  a  very  useful  substitute 
for  fresh  milk  :  the  food  is  prepared  from  it  with  boiled 
water,  and  is  free  from  bacterial  contamination. 

Mixed  Feeding. — When  the  mammary  secretion  is  insuffi- 
cient in  quantity  for  the  child's  needs,  but  otherwise  suitable, 
artificial  feeding  should  be  used  in  addition,  breast  and  bottle 
being  given  alternately,  or  the  one  in  the  daytime,  the  other 
at  night.     Infants  thrive  well  upon  this  method. 

Wet-nursing. — If  serious  difficulty  is  experienced  in 
feeding  the  infant  upon  cow's  milk,  and  ass's  milk  is  not 
available,  a  wet-nurse  is  the  only  remaining  alternative,  and 
the  value  of  this  method  of  feeding  delicate  infants  cannot 
be  over-estimated.  It  would  be  much  more  widely  employed 
but  for  the  difficulty,  so  frequently  experienced,  of  obtaining 
the  services  of  a  suitable  nurse. 

The  selection  of  a  wet-nurse  throws  a  serious  responsi- 
bility upon  the  medical  man.  He  must  be  satisfied  that  the 
breasts  are  secreting  freely,  the  nipples  healthy  and  well- 
formed,  and  the  genital  organs  healthy.  The  nurse  and  her 
child  must  both  be  free  from  any  taint  of  constitutional 
disease,  such  as  syphilis  and  tubercle.  In  addition  she  must 
be  of  good  physique,  with  sound  teeth,  cleanly  in  habits  and 
of  good  moral  character.  It  is  therefore  necessary  for  the 
medical  man  to  make  a  complete  physical  examination  of 
the  mother  and  her  child  before  selecting  a  wet-nurse.  It 
is  difficult  to  obtain  the  services  of  women  of  respectable 
character  as  wet-nurses,  and  in  any  case  the  greatest  care  is 
required  to  ensure  against  frauds  which  a  candidate  may 
easily  practise,  as  for  instance,  the  substitution  of  another 
child  for  her  own.  A  syphilitic  infant  must  not  be  brought 
up  by  a  wet-nurse. 

40—2 


628  THE   NEW-BORN   CHILD 

If  there  is  any  doubt  as  to  the  nurse's  freedom  from 
syphilis,  the  Wassermann  test  may  be  applied. 

Management  of  Premature  Infants. — Premature  infants 
are  distinguished  bj^  being  below  the  average  length  and 
weight,  by  deficiency  of  subcutaneous  fat,  by  persistence  of 
lanugo  hair,  and  by  a  low  degree  of  vigour,  as  compared  with 
the  fuU-time  healthy  child  (Figs.  280  and  281). 

Much  greater  care  is  required  in  the  management  of  an 
infant  three  or  four  weeks  premature  than  of  one  at  full 
term,  for  prematurity  implies  a  low  heat  production  and 
indifferent    digestive    activity.     Incubation    of    premature 


Fig.  280.- — -Premature  infant,  weight  4  lbs.     The  skin  is  much 
wrinkled,  and  the  child  is  crying  feebly. 

infants  has  been  much  employed,  but  it  is  doubtful  whether 
it  is  really  necessary,  except  in  the  case  of  infants  of  not 
more  than  three  pounds'  weight.  The  incubator  generally 
used  in  this  country  (Fig.  282)  is  heated  by  hot-water  bottles, 
which  are  placed  in  a  closed  chamber  under  the  infant's 
bed  ;  ventilation  is  permitted  by  apertures  of  entrance 
which  communicate  with  this  chamber,  and  ajoertures  of 
exit  under  the  roof  ;  a  thermometer  fixed  to  one  of  the  glass 
walls  enables  the  temperature  to  be  kept  under  observation. 
A  fairly  uniform  temperature  can  be  maintained  (about  85° 
to  90°  F.),  but  ventilation  is  very  imperfect,  and  the  infant 
undoubtedly  suffers  from  want  of  fresh  air.  Experience 
shows  that  with  infants  of  over  three  pounds  equally  good 


PREMATURE   INFANTS 


629 


results  may  be  obtained,  by  keeping  the  child  in  a  warm, 
well-ventilated  room  (about  70°  F.)  ;  it  should  be  screened 
froni  draughts,  and  the  bed  in  which  it  lies  can  be  kept  at  a 
temperature  of  about  100°  F.  by  the  use  of  hot-water  bottles 
rolled  up  in  blankets.  The  child  should  not  be  dressed  in  the 
ordinary  manner,  but  wrapped  up  in  sheets  of  cotton-wool  or 


Fig.  281. — Full-time  infant,  weight  8  lbs.  The  outlines  of  the 
face  are  rounded,  there  are  few  wrinkles,  and  the  child  is 
crying  lustily. 

Gamgee  tissue.  It  should  be  disturbed  as  little  as  possible, 
and,  although  bathing  is  not  advisable,  the  skin  may  be 
kept  clean  by  the  daily  use  of  olive  oil,  with  which  the  whole 
body  should  be  freely  smeared  ;  this  probably  has  also  a 
certain  nutritive  value,  some  of  the  fat  being  absorbed  by 
the  skin. 

Feeding  may  present  some  difficulties.    Premature  infants 
weighing  four  to  five  pounds  can  usually  take  the  breast 


630 


THE   NEW-BORN   CHILD 


satisfactorily  ;  if  not,  the  breast  milk  may  during  the  first 
few  days  be  withdrawn  by  a  breast-pump,  and  administered 
with  a  spoon  ;  this,  however,  cannot  be  continued  for  long. 
It  is  well  to  begin  the  feeding  of  a  premature  infant  without 
delay,  and  the  whey-cream  mixture  (see  p.  626)  is  the  best 
artificial  food  for  the  first  two  or  three  days  ;  of  this  a  tea- 
spoonful  may  be  given  every  hour,  until  the  breast  secretion 
is  available.  These  infants  sleep  nearly  continuously,  and 
must  be  regularly  roused  for  their  feeds.  When  breast  milk 
cannot  be  used,  the  amount  of  whey  and  cream  should  be 
increased  to  half  an  ounce  every  two  hours  by  the  end  of  the 


Fig.  282. — Incubator  for  Premature  Infants. 

first  week,  when  a  modified  cow's  milk  may  be  substituted 
for  it.  Cow's  milk  when  used  must  be  given  more  dilute — ■ 
i.e.,  with  a  larger  proportion  of  water — than  in  the  case  of  a 
full-time  child,  and  the  strength  must  be  very  cautiously 
increased.  Sodium  citrate  is  particularly  useful  in  assisting 
the  digestion  of  the  caseinogen.  The  amount  and  concentra- 
tion of  the  food  should  be  very  cautiously  increased.  If  the 
child  cannot  suck  through  a  teat,  the  food  should  be  dropped 
gently  and  slowly  into  its  mouth  through  a  glass  pipette. 
Sometimes  premature  infants  are  at  first  too  feeble  to 
swallow,  and  they  must  then  be  fed  through  a  narrow  soft 
rubber  catheter  passed  into  the  stomach. 

Premature  infants  lose  comparatively  little  weight  during 


DIGESTIVE   DISTURBANCES  631 

the  first  week,  as  the  amount  of  meconium  and  urine  which 
they  pass  is  small.  Even  when  no  difficulties  in  feeding  are 
encountered  the  rate  at  which  they  gain  weight  is  very  slow 
for  the  first  three  or  four  weeks. 

Digestive  Disturbances. — In  breast-fed  babies  digestive 
disturbances  are  rare  when  the  mother  is  healthy,  the  con- 
dition of  the  mammary  glands  satisfactory,  and  the  neces- 
sary precautions  are  observed  in  keeping  the  nipples  and  the 
child's  mouth  clean.  In  bottle-fed  babies  they  are  much  more 
common,  and  are  due  either  to  the  kind  of  food  in  use  being 
unsuitable  to  the  child,  or  from  failure  to  observe  the 
necessary  rules  of  cleanliness  already  laid  down.  Digestive 
disturbances  are  indicated  in  infants  by  abdominal  symptoms 
such  as  colic,  vomiting,  constipation,  or  diarrhoea  ;  by  the 
parasitic  eruption  known  as  thrush,  and  by  loss  of  weight  or 
failure  to  increase  in  weight.  Colic  is  indicated  by  attacks 
of  violent  screaming,  in  which  the  legs  are  drawn  up  to  the 
abdomen  ;  the  attacks  are  often  suddenly  relieved  by  the 
passage  of  flatus.  Vomiting  after  feeding  may  be  due  to  the 
infant  having  over-filled  its  stomach  or  taken  its  meal  too 
quickly  ;  sometimes  it  is  due  to  the  food  containing  an  excess 
of  fat.  In  cases  of  persistent  vomiting  the  possibility  of 
pyloric  stenosis  must  not  be  overlooked.  This  condition  is 
characterised  by  frequent  attacks  of  vomiting,  in  which  the 
ejected  food  is  thrown  out  with  remarkable  violence,  the 
so-called  projectile  vomiting.  When  this  sign  is  not  present, 
physical  evidences  of  dilatation  of  the  stomach  may  be  found, 
the  peristaltic  wave  crossing  the  epigastrium  from  left  to 
right  being  fairly  characteristic.  Diarrhoea  is  usually  accom- 
panied by  a  greenish  discoloration  of  the  stools,  the  result 
of  an  acid  fermentation,  and  sometimes  in  bad  cases  they 
contain  fragments  of  undigested  milk  curd.  It  also  usually 
causes  redness  and  irritation  of  the  skin  around  the  anus, 
which  may  spread  over  the  buttocks  and  inner  sides  of  the 
thighs.  Thrush  is  characterised  by  the  appearance  of  a  crop 
of  slightly  elevated,  circular,  white  spots  in  the  mouth  and 
throat,  and  sometimes  within  and  around  the  anus.  They 
are  due  to  a  fungus — o'idium  albicans — which  can  be  readily 
detected  by  the  microscope  in  the  scrapings  from  these 
patches.  It  is  always  accompanied  by  some  or  all  of  the 
symptoms  of  disturbed  digestion.     On  inquiry  the  condition 


632  THE   NEW-BORN   CHILD 

can  usually  be  traced  to  the  use  of  dirty  bottles  or  teats,  or 
to  lack  of  attention  to  the  child's  mouth.  Wasting  from 
unsuitable  feeding  must  be  distinguished  from  constitutional 
conditions  such  as  syphilis. 

Digestive  disturbances  are  to  be  treated  not  so  much  by 
drugs  as  by  regulation  of  the  quantity  and  quality  of  the  food, 
and  by  strict  attention  to  cleanliness.  A  common  error  in 
artificial  feeding  is  giving  the  food  in  a  too  concentrated 
state  ;  no  rule  will  apply  to  every  case,  and  increased  dilution 
may  often  be  advisable  even  when  the  food  is  apparently  not 
too  concentrated.  The  poor  often  administer  starchy  food 
to  very  young  infants  ;  this  is  quite  unsuitable,  for  the 
amylolytic  digestive  ferments  are  undeveloped  in  the  infant. 
Another  common  error  is  the  use  of  artificially  prepared 
patent  foods  for  infants  ;  these  are  all  deficient  in  fat, 
which  is  one  of  the  most  useful  and  most  easily  digested 
elements  of  an  infant's  food,  and  wasting  is  accordingly  very 
ajot  to  occur.  Barley-water  or  rice-water  may  be  used  instead 
of  plain  water  for  diluting  the  milk  in  digestive  disturbances. 
If  the  child  does  not  thrive  on  cow's  milk  prepared  in  the 
manner  described,  a  wet-nurse  or  a  supply  of  '  humanised  ' 
milk  or  of  ass's  milk  should  be  obtained  instead.  Constipa- 
tion can  often  be  relieved  by  a  slight  alteration  in  the  food  ; 
increased  dilution  or  the  addition  of  an  excess  of  cream  will 
often  suffice.  Drugs  should  be  avoided,  but  5j.  of  olive  oil 
may  be  given  occasionally  when  required.  Diarrhoea  is  best 
treated  by  a  single  dose  of  a  mixture  of  castor  oil  5ss.,  with 
olive  oil  5iss.,  followed  by  a  change  of  feeding.  Severe  cases 
of  diarrhoea  with  vomiting  may  be  treated  as  follows  :  a  tea- 
spoonful  or  two  of  boiled  water  (warm)  every  hour  for  twelve 
hours  ;  then  a  teaspoonful  of  whey  every  hour  for  twelve 
hours  ;  then  two  teaspoonfuls  of  the  whey-cream  mixture 
every  hour  for  twelve  hours.  Thrush  needs  no  special  treat- 
ment beyond  the  cleansing  of  the  mouth  with  boro-glyceride, 
and  attention  to  the  food  and  to  the  condition  of  the  bottles 
and  teats. 

Acute  gastro-enteritis  may  result  from  persistence  in 
unsuitable  feeding,  or  from  infection  of  the  alimentary  canal 
by  contaminated  milk.  It  is  almost  unknown  in  breast-fed 
babies.  It  is  one  of  the  most  serious  disorders  of  early 
infancy,  and  is  attended  by  a  high  mortality.     The  chief 


ASPHYXIA  633 

symptoms  are  persistent  vomiting  and  diarrhoea,  with 
collapse,  indicated  by  coldness  and  cyanosis  of  the  face  and 
limbs.  There  is  usually  great  irritation  and  some  excoriation 
of  the  skin  of  the  buttocks,  and  general  cutaneous  eruptions 
of  varied  types  and  distribution  are  often  present.  The 
treatment  is,  in  the  first  place,  to  stop  the  administration  of 
food  entirely  for  twenty-four  to  forty-eight  hours  ;  during 
this  period  sterile  saline  solution  may  be  injected  under  the 
skin,  with  strict  antiseptic  precaution,  in  small  quantities  of 
about  1  ounce  every  three  or  four  hours.  Then  boiled  water 
or  albumen  water  in  small  quantities  should  be  given,  and  if 
a  wet-nurse  cannot  be  obtained,  the  whey-cream  mixture 
may  be  cautiously  given  or  well-diluted  peptonised  cow's 
milk.  The  question  of  food  is  all-important,  drugs  being  of 
little  use. 

Obstetric  Injuries  and  Diseases  of  the  Foetus 

Asphyxia  Neonatorum  (Still-birth). — Asphyxia,  which 
literally  means  pulselessness,  has  come  by  usage  to  mean 
interruption  of  the  respiratory  function,  and  is  now  used  in 
this  sense  only.  Asphyxia  in  the  new-born  child  may  arise 
i7i  utero  from  complications  of  labour,  in  which  case  the  child 
is  born  asphyxiated  (intra-uterine  suffocation);  or  it  may  arise 
from  failure  to  establish  pulmonary  respiration  when  born, 
in  which  case  the  asphyxia  comes  on  after  delivery.  The 
latter  is  very  rare,  the  former  is  common. 

Respiration,  as  it  is  found  in  the  foetus  in  utero,  consists  in 
a  gaseous  exchange  between  the  foetal  blood  and  the  maternal 
blood  effected  through  the  placenta.  Therefore  anything 
which  causes  interruption,  partial  or  complete,  of  the  placental 
circulation,  either  foetal,  through  the  villi,  or  maternal, 
through  the  inter-villous  spaces,  will  tend  to  induce  intra- 
uterine asphyxia.  The  following  conditions  may  accordingly 
cause  it  :  (a)  Premature  detachment  of  the  placenta  (ante- 
partum haemorrhage),  {b)  Compression  of  the  cord  (cord 
prolapsed,  or  tightly  coiled  round  the  foetus,  or  caught  by  the 
after-coming  head),  (c)  Tonic  uterine  contraction,  causing 
continuous  compression  of  the  placenta.  These  conditions 
may  all  be  complicated  by  blocking  of  the  foetal  air-passages 
with  fluids  from  premature  respiration  in  utero,  due  either  to 


634  THE   NEW-BORN   CHILD 

cutaneous  stimulation  (breech  cases),  or  to  partial  inter- 
ference with  the  placental  circulation,  which,  by  causing 
accumulation  of  carbonic  acid  in  the  blood,  stimulates  the 
respiratory  centre  before  paralysing  it. 

Failure  to  establish  the  pulmonary  respiratory  function 
after  birth  may  be  due  to  (a)  head  injuries  causing  inter- 
ference with  the  action  of  the  respiratory  or  vaso-motor 
centres  in  the  medulla  ;  and  (6)  such  congenital  defects  as 
stenosis  of  the  trachea  or  the  pulmonary  artery.  Obviously 
cases  may  be  met  with  in  which  the  causation  is  complex — 
e.g.  blocking  of  the  air-passages  with  fluids  may  be  associated 
with  injury  to  the  head  received  in  difficult  labour. 

The  asphyxial  phenomena  in  new-born  infants  will 
depend  in  the  main  upon  the  extent  and  duration  of  the 
interference  with  the  placental  circulation  which  has  pre- 
ceded delivery.  The  commencement  of  the  process  of 
asphyxia  is  characterised  by  cyanosis  and  high  blood- 
pressure  ;  this  phase  is  commonly  known  as  cyanotic  or  blue 
asphyxia.  Later  on  the  blood-pressure  is  reduced,  the  cir- 
culation fails,  and  the  skin  becomes  pale  ;  this  phase  is  called 
pallid  or  white  asphyxia,  and  is,  of  course,  more  serious  than 
the  former. 

Cyanotic  Form. — This  form  of  asphyxia  is  characterised 
by  the  deep  blue  or  purple  tint  of  the  skin,  and  by  other 
appearances  suggestive  of  suffocation — e.g.  haK-opened  eye- 
lids and  injected  conjunctivae  ;  there  is  also  slight  muscular 
rigidity  of  the  limbs,  with  preservation  of  the  cutaneous 
reflexes.  The  heart  usually  beats  vigorously,  and  its  move- 
ments can  be  readily  seen  and  felt  through  the  chest-wall ; 
sometimes  in  more  severe  cases  only  feeble  cardiac  movements 
can  be  detected. 

Pallid  Form. — In  this  form  the  skin  is  blanched,  the  limbs 
are  flaccid  from  complete  loss  of  muscular  tone,  the  eyes 
closed,  the  pupils  dilated,  the  umbilical  cord  almost  pulseless, 
and  the  cardiac  movements  feeble  ;  they  may  be  unrecog- 
nisable except  by  the  stethoscope.  All  the  reflexes,  super- 
ficial and  deep,  are  lost,  the  sphincters  often  being  relaxed 
so  that  urine  and  meconium  escape. 

In  both  forms  the  child  makes  no  voluntary  movements  ; 
hence  the  time-honoured  name  of  still-birth  applied  to  the 
condition. 


ASPHYXIA  635 

The  probability  of  the  child  being  born  in  a  condition 
of  asphyxia  may  be  sometimes  foretold  during  labour  ;  thus 
direct  evidence  of  foetal  distress  may  be  afforded  by  slowing 
and  enfeeblement  of  the  foetal  heart-sounds,  or  by  the 
passage  of  meconium  in  cases  other  than  breech  presentations. 
In  breech  presentations,  difificult  forceps  cases,  and  cases  of 
ante-partum  haemorrhage,  there  is  always  an  increased  risk 
of  still-birth.  Accordingly,  under  all  such  circumstances, 
preparations  for  resuscitation  should  be  made  before  delivery. 

Treatment. — ^The  first  step  is  to  clear  the  mouth  and 
throat  of  fluids  ;  this  may  be  done  by  laying  the  child  on  its 
side  and  wiping  out  the  throat  with  pledgets  of  wet  cotton- 
wool ;  or  by  holding  it  up  by  the  feet  for  a  moment  or  two  so 
as  to  allow  retained  fluid  to  escape  from  the  throat.  In  a 
case  of  cyanotic  asphyxia  attention  may  then  be  solely 
directed  to  exciting  the  respiratory  centre  ;  in  a  case  of  pallid 
asphyxia,  cardiac  is  quite  as  important  as  respiratory  stimu- 
lation. The  treatment  of  the  two  conditions  is  accordingly 
somewhat  different. 

In  cyanotic  asphyxia,  when  the  heart  beats  strongly, 
vigorous  measures  may  be  adopted,  such  as  sprinkling  the 
chest  with  cold  water,  flicking  the  trunk  with  a  towel  dipped 
in  cold  water,  or  momentarily  immersing  the  trunk  and  limbs 
of  the  child  in  tepid  and  warm  baths  alternately  (temperature 
about  60°  and  105°  F.)  ;  or,  while  in  a  warm  bath,  cold  water 
may  be  sprinkled  over  its  head.  As  the  cutaneous  reflexes 
are  preserved,  these  measures  usually  produce  a  considerable 
effect  upon  the  respiratory  centre.  If  they  fail  to  excite  any 
response,  artificial  respiration  must  be  at  once  employed. 
When,  in  this  form,  the  cardiac  pulsations  are  feeble  at  the 
outset,  artificial  respiration  should  be  begun  as  soon  as  the 
throat  has  been  cleared. 

In  pallid  asphyxia  the  greatest  care  must  be  taken  to 
preserve  the  body-heat  and  to  maintain  the  circulation.  A 
useful  method  is  to  immerse  the  infant's  body  in  a  warm  bath 
(105°  F.)  for  several  minutes,  holding  its  head  clear,  gentle 
friction  being  used  meanwhile  to  the  trunk  and  limbs  ;  by 
gently  compressing  the  base  of  the  chest  between  the  hands, 
and  then  allowing  the  chest-wall  to  recoil,  artificial  respira- 
tion may  be  practised  at  the  same  time.  Or  the  child,  may 
be  laid  over  a  hot-water  bottle  well  protected  with  blankets, 


636 


THE   NEW-BORN   CHILD 


and  a  rectal  injection  of  gj.  to  gij.  of  warm  saline  solution  may 
be  administered.  Cutaneous  stimulation  of  the  resjDiratoiy 
centre  is  impracticable,  as  the  cutaneous  reflexes  are  lost, 


H 


Fig.  283. — Schultze's  Method  of  Artificial  Eespiration. 
Fii'st  or  Inspii'atory  Position. 


and  accordmgly  artificial  respiration  should  be  begun  with 
as  little  delaj'  as  possible. 

-  Methods  of  Artificial  Respiration. — While  many  may  be 
practised  upon  the  adult,  only  three  are  of-  practical  import- 
ance in  the  case  of  the  new-born  child. 


ASPHYXIA 


637 


(1)  Schultze's  Method. — The  body  of  the  child  is  held  by 
the  shoulders,  the  thumbs  passing  over  the  clavicles,  the 
fingers  supporting  the  back  ;  the  ulnar  margins  of  the  hands 
are  sufficiently  separated  to  allow  the  head  to  lie  between 
them  in  a  position  mid- 
way between  flexion  and 
extension,  so  as  to  allow 
free  passage  of  air 
through  the  glottis.  This 
is  the  first  or  inspiratory 
position  (Fig.  283)  :  the 
lower  limbs  hang  down, 
so  that  the  trunk  is  ex- 
tended ;  in  this  attitude 
the  diaphragm  is  drawn 
down  to  the  lowest  possi- 
ble level,  and  air  is  thus 
drawn  into  the  lungs. 
The  body  of  the  child  is 
then  swung  lightly  into 
the  position  shown  in 
Fig.  284  ;  this  is  the 
second  or  expiratory  posi- 
tion. The  trunk  is  now 
flexed,  and  the  weight  of 
the  lower  limbs  and  the 
abdominal  viscera  is 
thrown  upon  the  dia- 
phragm, causing  it  to 
ascend  and  expel  air 
from  the  lungs.  Next 
the  body  of  the  child 
is  allowed  to  fall  back 
gently  into  the  first  posi- 
tion.      The    head    must 

be  held  steady  by  the  wrists  during  these  movements, 
and  not  allowed  to  fall  forwards  against  the  chest,  or  the 
passage  of  air  through  the  glottis  will  be  impeded.  The 
movements  should  be  regulated  so  as  to  produce  about 
twelve  to  fourteen  respirations  a  minute.  The  reversed 
position  of  the  trunk  in  the  expiratory  movement  is  also 


/ 


Fig.  284. — Schultze's  Method  of  Arti- 
ficial Eespiration.  Second  or  Ex- 
piratory Position. 


638 


THE  NEW-BORN   CHILD 


useful  in  promoting  the  escape  of  fluid  from  the  air-passages. 
When  the  body  is  thickly  covered  with  vernix  a  handkerchief 
or  towel  must  be  used  to  hold  it  securely. 

(2)  Sylvester's  Method. — The  child's  body  is  laid  on  its 
back,  a  pillow  being  placed  beneath  the'  shoulders,  and  the 
head  allowed  to  hang  over  the  end  in  a  position  midway 
between  flexion  and  extension.  If  necessary  the  body  may 
be  kept  warm  by  placing  beneath  it  a  hot-water  bottle  well 
protected  in  a  blanket.  The  tongue  should  be  pulled  out 
with  the  corner  of  a  handkerchief,  and  an  assistant  is  required 
to  hold  the  feet  steady  (Fig.  285).     The  arms  are  then  seized 


Fig.  285. — Sylvester's  Method  of  Artificial  Eespiration. 
First  or  Inspiratory  Position. 

by  the  elbows  and  gently  but  firmly  carried  round  by  an 
upward  and  outward  sweep  until  they  lie  at  the  sides  of  the 
head  (inspiration)  ;  next  the  arms  are  pressed  against  the 
chest-wall  (expiration)  (Fig.  286).  These  movements  are 
made  at  about  the  same  rate  as  in  the  former  method. 

Tongue  Traction. — By  seizing  the  tip  of  the  tongue  in  the 
corner  of  a  handkerchief,  and  pulling  it  firmly  forwards, 
traction  is  made  upon  the  larynx,  and  this  powerfully  excites 
the  respiratory  centre  ;  a  distinct  gasp  usually  follows  imme- 
diately. By  repeating  traction  at  regular  intervals  respira- 
tion may  be  maintained  in  favourable  cases.  This  reflex  is 
often  preserved  after  all  the  cutaneous  reflexes  have  been 
lost,  but  in  bad  cases  of  pallid  asphyxia  it  may  fail  entirely. 


ASPHYXIA 


639 


This  method  can  conveniently  be  employed  along  with 
Sylvester's  method,  or  while  the  infant  is  in  the  warm  bath. 
(3)  Insufflation. — This  method  is  only  required  when  the 
air-passages  have  become  waterlogged  by  premature  respira- 
tion in  utero  ;  great  difficulty  may  then  be  experienced  in 
causing  air  to  enter  the  lungs  by  the  methods  of  artificial 
respiration  just  described.  Insufflation  may  be  practised  by 
the  mouth-to-mouth  method,  or  by  catheterisation  of  the 
trachea.  The  former  is  not  to  be  advised,  for  the  greater 
part  of  the  air  blown  into  the   mouth  passes  down  the 


Fig.  286.-p-Sylvester's  Method  of  Ai-tificial  Eespiration. 
Second  or  Expiratory  Position. 

oesophagus  into  the  stomach  instead  of  through  the  glottis. 
When  insufflation  is  indicated  the  latter  method  should  be 
adopted.  An  ordinary  gum-elastic  catheter  is  the  only 
instrument  required  ;  in  introducing  it  the  index  finger  of  the 
right  hand  should  be  passed  into  the  throat,  over  the 
epiglottis,  and  the  catheter  directed  along  its  palmar  surface 
into  the  larynx.  When  carefully  introduced  no  injury  will 
be  caused  to  the  soft  parts  by  the  catheter.  Air  may  be  now 
gently  blown  into  the  trachea,  and  if  fluid  is  present  this  will 
bubble  up  at  the  sides  of  the  catheter  into  the  mouth,  and  can 
be  wiped  away.  When  most  of  the  fluid  seems  to  have  been 
expelled,  Sylvester's  method  of  artificial  respiration  should  be 


640 


THE  NEW-BORN   CHILD 


resorted  to,  with  the  catheter  left  in  position.  Used  in  this 
manner  for  merely  freeing  the  air-passages,  insiiflfiation  is 
useful.  As  a  method  of  artificial  res23iration  it  is  unsatis- 
factor}^,  first  because  of  the  risk  of  rupturing  the  pulmonary 
vesicles  and  causing  emphysema  bj^  blowing  air  too  vigorously 
into  them  ;  and  secondly,  because  the  au'  thus  mtroduced 
into  the  child's  lungs  is  exhausted  air,  loaded  with  various 
impurities,  and  consequently  unsuitable  for  resuscitation. 
Ribemont-Dessaignes  has  invented  an  msuflflator,  by  means 
of  which  atmospheric  aii'  can  be  blown  dnectly  into  the 
trachea,  thus  neutralising  the  latter  objection  (Fig.  287). 

Schultze"s  method  should  not  be  employed  m  cases  of 
palhd  asphyxia  on  account  of  the  handling  and  exposure  of 


Fig.  287. — Eibeinont-Dessaignes's  Insufflator. 

the  child  which  it  entails.  Great  care  and  gentleness  must  be 
exercised  m  carrying  out  the  manipulations.  Rupture  of  the 
liver  or  the  spleen  may  be  caused  by  too  vigorous  compression 
of  the  trunk  in  either  method.  While  performing  artificial 
respnation,  care  should  be  taken  not  to  interfere  with  the 
first  u-regular  spontaneous  attempts  to  breathe  which  the 
child  may  make.  At  first,  long  intervals  occur  between 
these  attempts,  during  which  artificial  respiration  must  be 
resumed.  The  condition  of  the  heart  must  be  carefully 
watched.  iVs  long  as  cardiac  pulsations  can  be  made  out 
with  the  stethoscope  there  is  a  chance  of  success  ;  when  these 
have  definitely  ceased  the  child,  of  course,  is  dead.  In  cases 
of  pallid  asj^hj'xia  after  successful  resuscitation  the  child  often 
remains  very  feeble,  and  may  die  m  two  or  three  days  from 


CRANIAL  INJURIES 


641 


cerebral  injury  or  from  pneumonia — e.g.  if  fluids  have  been 
drawn  into  the  air-passages.  The  prognosis  after  successful 
resuscitation  is  much  more  favourable  with  the  cyanotic  form. 

Injuries  to  the  Head. — As  a  result  of  injury  during  labour 
hcemorrhage  may  occur  either  outside  or  within  the  cranial 
cavity,  or  fracture  indentations  of  the  skull  bones  may  be 
found. 

Hcemorrhage  may  occur  in  four  different  strata  :    (a)  into 
the  deep  cellular  layer  of  the  scalp,  i.e.,  the  same  position  as  a 
caput  succedaneum  ;    (6)  beneath  the  pericranium  and  the 
aponeurosis    of    the    occipito- 
frontalis  muscle  ;    (c)  between 
the  pericranium  and  the  bone 
(cephalhaematoma)  ;      (d)    be- 
tween the  bone  and  the  dura 
mater     (extra-dural      haemor- 
rhage) ;      (e)     into    the     pia- 
arachnoid    or   the   brain    sub- 
stance (cerebral  haemorrhage). 

The  hsemorrhages  which 
occur  in  the  scalp  are  not  of 
great  clinical  importance  ;  the 
other  varieties  deserve  some 
consideration. 

Cephalhcematoma.  —  This 
condition  consists  in  an  effu- 
sion of  blood  beneath  the  peri- 
cranium, due  to  detachment  of 
this  membrane  during  labour. 
Usually  the  effusion  takes  place  gradually,  and  the  swelling 
may  not  appear  for  a  day  or  two  after  birth  ;  but  it  may  be 
found  on  the  head  at  birth.  The  cause  of  the  separation  of 
the  pericranium  is  unknown ;  the  bone  is  very  seldom  injured, 
and,  though  usually  occurring  after  a  difficult  labour,  it  is 
occasionally  seen  after  a  normal  and  easy  delivery. 

The  usual  situation  is  upon  one  or  other  parietal  bone  ; 
sometimes  it  is  bilateral,  affecting  both  parietal  bones  ;  more 
rarely  multiple  cephalhgematomata  are  met  with.  The  swell- 
ing varies  a  good  deal  in  size  ;  it  may  be  no  larger  than  a 
walnut,  when  the  area  of  detached  periosteum  is  small ;  it 
may,   however,   attain  the  large  size   shown  in  Fig.  288. 

E.M.  41 


Fig.  288. — Double  Ceplialhsema- 
toma.  (Eibemont-Dessaignes 
and  Lepage.) 


642  THE   NEW-BORN   CHILD 

Though  hmited  by  the  sutures  to  the  area  of  the  affected 
bone  because  at  the  sutures  dura  mater  and  pericranium  are 
united,  the  effusion  seldom  spreads  over  the  whole  surface 
of  the  bone,  but  is  confined  to  a  portion  of  it.  At  first  it  is 
soft  and  fluctuating,  but  soon  a  dense,  hard,  rounded  edge 
forms  around  it,  due  to  osteoplastic  changes  at  the  margins  of 
the  effusion.  The  blood  remains  fluid  in  the  centre  and  is 
gradually  absorbed,  but  several  months  may  elapse  before  it 
entirely  disappears.  No  treatment  is  necessary  ;  incision  or 
puncture  is  inadvisable. 

Intra-cranial  Hmmorrhages  are  by  no  means  uncommonly 
found   in   cases   of   still-birth,    and   premature   infants   are 
specially  susceptible  of  this  injury  on  account  of  the  imperfect 
ossification  of  the  cranial  bones.     In  130  autopsies  on  still- 
born infants  Spencer  found  that  40  per  cent,  of  them  showed 
intra-cranial  haemorrhages,  the  greater  number  being  extra- 
dural in  position.     All  the  still-born  infants  in  his  series 
which  had  been  delivered  by  forceps  showed  this  condition. 
Very  similar  results  have  been  obtained  by  Wallich  in  a  series 
of  143  still  births.     Intra-cranial  haemorrhage  is,  however, 
not  confined  to  cases  of  instrumental  delivery,  as  it  has  been 
sometimes    found    when    delivery    has    been    natural    and 
apparently  easy.    Extra-dural  haemorrhages  are  usually  asso- 
ciated with  fracture  or  fracture-indentation   of  the  skull. 
Extensive  intra-cranial  haemorrhage  occurring  during  labour 
always  results  in  the  child  being  still-born  ;   occasionally  the 
condition  develops  after  birth  and  the  child  may  live  for  a 
few  days.     The  diagnosis  is  then  a  matter  of  much  difficulty  ; 
localising  symptoms  cannot  be  expected  to  develop,  but 
certain  general  signs  indicative  of  intra-cranial  bleeding  may 
be  observed.     In  the  early  stages  the  infant  is  constantly 
drowsy,  the  pulse  is  slow  (below  100),  and  the  fontanelles  are 
bulging  and  tense  ;   later  on  trismus,  dysphagia  and  con- 
vulsions occur.     If  a  depressed  fracture  is  associated  with  it, 
or  other  signs  of  injury  to  the  skull,  the  diagnosis  is  of  course 
more  readily  made.     In  such  cases  an  operation  upon  the 
site  of  the  fracture  may  be  undertaken,  but  naturally  the 
prospect  of  success  is  small. 

Intra-dural  Spinal  Hcemorrhages  have  been  found  in  still- 
born infants  from  difficult  breech  labours. 

Depression  and  Depressed  Fractures  of  the  Bodies. — This 


CRANIAL   INJURIES 


643 


injury  usually  results  from  the  pressure  of  the  sacral  pro- 
montory upon  the  part  of  the  head  with  which  it  is  in  contact. 
The  indentation  or  depression  is  usually  oval  and  spoon- 
shaped,  or  shallow  and  gutter-shaped  ;  in  the  former  the 
depression  is  deep  at  one  end  of  the  oval  and  gradually  rises 
to  the  level  of  the  general  surface  of  the  head  at  the  other. 
The  posterior  parietal  bone  is  therefore  the  one  usually 


Fig.  289. — Spoon- si  aped  Indentation  of  the  Eight  Frontal  Bone. 
The  dotted  lines  show  the  position  of  the  anterior  fontanelle. 


affected,  and  it  is  much  more  likely  to  be  caused  by  a  flat 
than  by  a  normal-shaped  pelvis.  More  rarely  it  is  seen  upon 
the  posterior  part  of  the  frontal  bone,  as  a  result  of  the  lateral 
gliding  movement  of  the  head  which  occurs  in  natural 
delivery  through  a  markedly  flat  pelvis  (Fig.  290).  The  spoon 
shape  is  probably  produced  by  the  transverse  gliding  move- 
ment, the  posterior  end  of  the  depression  being  deeper  than 
the  anterior.  It  is  not  always  easy  to  decide  whether  or 
not  the  depressed  bone  is  also  fractured.     No  treatment  is 

41—2 


644 


THE   NEW-BORN  CHILD 


required  as  a  rule,  for  the  bone  gradually  rises  into  its  proper 
position  ;  occasionally  signs  of  cerebral  compression  occur, 
and  then  an  operation  to  elevate  it  can  be  practised. 

Fissured  Fracture  of  the  Skull. — This  injury  is  almost 
always  due  to  difficulty  in  delivering  the  head  by  forceps  or 
version  ;  but  it  may  sometimes  occur  after  spontaneous 
delivery  in  cases  of  contracted  (fiat)  pelvis.  The  posterior 
parietal  bone  is  the  one  most  commonly  injured,  and  it  is 
compressed  by  the  sacral  promontory  (Fig.  290).     Fracture 


Fig.  290.  — Depressed  Fracture  of  the  Left  Parietal  Bone  caused  by 
Labour  in  a  Flat  Pelvis.     (Buinm.) 


may  be  complete  or  incomplete  ;    often  it  is  depressed  and 
associated  with  meningeal  haemorrhage. 

Birth  Paralyses.  —  Facial  Paralysis. — ^This  injury  is 
usually  caused  by  forceps  delivery,  and  is  due  to  compression 
of  the  facial  nerve  in  the  parotid  region  by  the  blade.  A  few 
cases  have,  however,  been  observed  after  spontaneous 
delivery,  but  their  causation  is  quite  obscure.  The  resulting 
deformity  is  characteristic,  and  consists  in  an  extreme  lateral 
asymmetry  of  the  face.  On  the  paralysed  side  the  eye 
remains  open  as  the  orbicularis  is  paralysed  ;  the  naso- 
labial fold  is  obliterated  ;   the  mouth  is  open.     Owing  to  the 


FACIAL  PARALYSIS 


645 


action  of  the  unaffected  muscles  being  unopposed,  the  mouth 
is  drawn  over  to  the  sound  side  ;  the  naso-labial  fold  on  the 
same  side  is  deep.  When  the  child  cries  extreme  asymmetry 
is  produced.  Suckling  and  deglutition  are  not  affected. 
Often  a  skin  abrasion  can  be  seen  below  the  zygoma  on  the 
affected  side,  indicating  where  the  tip  of  the  forceps  blade 
has  caught  the  nerve.  As  a  rule,  the  nerve  recovers  spon- 
taneously in  a  day  or  two  ;  but  severe  cases  may  be  met 
with  in  which  a  certain  amount  of  paralysis  persists,  and 
local  electrical  treatment  will  then  be  necessary. 

Paralysis  of  the  Arm.- — The  mechanism  of  this  form  of 


Fig.  291.—  Facial  Paralysis  in  the  New-born  Child.     (Etidin.) 

paralysis  (generally  known  as  Duchenne's  palsy)  is  not  well 
understood,  but  the  immediate  cause  is  injury  from  over- 
stretching of  the  brachial  plexus  or  of  the  nerve  roots  which 
supply  it.  Difficulty  in  labour  is  almost  invariably  associated 
with  it,  but  some  cases  have  been  recorded  after  spontaneous 
labour.  The  muscles  most  commonly  affected  are  the  del- 
toid, biceps,  coraco-brachialis,  and  supinator  longus — i.e., 
the  muscles  supplied  by  branches  from  the  fifth  and  sixth 
cervical  nerves. 

Fractures  of  Limbs  result  from  unskilful  delivery  ;    they 
may  occur  in  breech  presentations,  in  delivering  the  legs,  or 


646  THE   NEW-BORN   CHILD 

from  difficulty  in  freeing  extended  arms  ;  or  in  head  pre- 
sentations when  there  is  difficulty  in  disengaging  the 
shoulders. 

Umbilical  Sepsis. — Septic  infection  through  the  navel  may 
occur  when  the  cord  is  divided,  during  the  process  of  sej)ara- 
tion,  or  subsequently.  Some  authorities  consider  that  it 
is  a  frequent  occurrence,  and  is  responsible  m  one  form  or 
another  for  about  10  per  cent,  of  the  mortahty  among  infants 
under  one  month  old.  This  opinion  is  based  mainly  uj)on  the 
results  of  autopsies,  which  frequently  show  internal  evidences 
of  sepsis  in  cases  in  which  its  existence  was  not  suspected 
during  life.  Local  signs  of  sejDtic  infection  of  the  navel  may 
be  seen  in  erysipelatous  inflammation  of  the  skin,  sloughing 
or  suppuration  at  the  line  of  demarcation,  often  accompanied 
by  haemorrhage,  or  a  sloughmg  condition  of  the  ulcer  left 
when  the  cord  has  come  away.  In  addition  to  these  obvious 
local  appearances,  septic  arteritis  and  phlebitis  may  occur, 
which  spread  rapidly  up  the  abdommal  portion  of  the  umbili- 
cal vessels  without  giving  rise  to  noticeable  external  changes. 
Such  cases  usually  terminate  in  general  dissemination  of 
the  septic  process  by  embolism.  In  tetanus  neonatorum,  a 
very  rare  affection,  the  organisms  probably  enter  at  the 
navel. 

The  only  effective  treatment  is  prophjdactic  ;  it  has  been 
suggested  that  the  cord  should  in  routine  j^i'actice  be  ampu- 
tated close  to  the  abdominal  wall,  and  the  skin  edges  united 
by  stitches  at  birth.  This  is  unnecessary  if  the  cord  is 
treated  systematically  with  proj)er  surgical  cleanliness.  The 
infant  should  be  sponged,  not  bathed,  until  the  cord  has 
separated  and  the  umbilicus  has  healed. 

Ophthalmia  Neonatorum. — This  condition  begins  as  an 
acute  purulent  conjunctivitis,  but  may  go  on  to  attack  the 
cornea,  when  it  may  result  in  partial  or  total  permanent 
blindness  from  opacity  ;  or  complete  disorganisation  of  the 
eyeball  from  perforation  of  the  cornea  may  occur.  In  a 
large  proportion  of  cases  of  persons  who  have  been  blind  from 
infancy,  gonorrhoeal  ophthalmia  has  been  the  cause  of  their 
loss  of  sight.  In  1,100  cases  of  blindness  in  children  recently 
investigated  b}^  Harman,  24  jjer  cent,  were  due  to  ophthalmia 
neonatorum.  Ophthalmia  is  due  to  mfection  ;  m  very  rare  in- 
stances this  may  occur  in  utero  from  infection  of  the  amniotic 


OPHTHALMIA  647 

fluid,  for  such  cases  have  been  recorded ;  in  the  great 
majority,  however,  the  infection  occurs  during  or  immediately 
after  labour  ;  in  a  smaller  but  quite  definite  proportion  it 
occurs  in  the  first  few  days  of  extra-uterine  life.  It  is  pro- 
bable that  infection  occurring  immediate^  after  birth  is  due 
to  particles  of  vaginal  discharge  which  cling  to  the  eyelids 
or  eyelashes,  and  gain  access  to  the  conjunctival  sac  when  the 
eyes  are  first  opened.  In  normal  labour  the  eyelids  are  tightly 
closed  and  probably  water-tight  during  the  birth  of  the  head, 
but  in  face  presentations  or  in  delivering  the  after-coming 
head  the  eyes  may  be  infected  by  the  examining  finger.  In 
about  60  per  cent,  of  cases  the  infection  can  be  proved  to  be 
gonorrhoeal  by  the  discovery  of  gonococci  in  the  pus  ;  in 
the  remainder  various  organisms  have  been  found,  including 
bacterium  coli,  pneumococcus,  Klebs-Loffler's  bacillus,  and 
the  pyogenic  micrococci.  Gonorrhoeal  cases  only  occur  by 
direct  infection  from  the  maternal  passages.  Other  organ- 
isms, not  derived  from  j)re-existing  disease  of  the  maternal 
passages,  may  also  obtain  access  in  the  same  manner.  A 
certain  proportion  of  the  non-gonorrhoeal  cases  are  probably 
of  a  simple  catarrhal  nature.  Complications  such  as  keratitis 
are  very  much  rarer  in  non-gonorrhoeal  than  in  gonorrhoeal 
cases. 

The  signs  of  ophthalmia  m.ake  their  appearance  during 
the  first  four  days  of  life  in  from  50  to  80  per  cent,  of  all 
cases  ;  very  few  cases  arise  later  than  the  first  week.  Gonor- 
rhoeal cases  begin  earlier  than  other  kinds,  because  infection 
is  early,  and  possibly  because  the  period  of  incubation  of  the 
gonococcus  is  short.  The  conjunctivae  become  greatly 
injected  and  excrete  a  free  purulent  discharge  ;  the  eyelids 
become  reddened  and  oedematous,  and,  from  spasm  of  the 
orbicularis  palpebrarum,  distension  of  the  conjunctival  sac 
with  pus  occurs.  On  gently  separating  the  eyelids,  the  dis- 
charge will  escape  in  large  quantities.  Usually  both  eyes 
are  affected,  either  simultaneously  or  consecutively  ;  when 
one  eye  at  first  escapes  it  is  difficult  to  preserve  it  from 
subsequent  infection. 

Treatment. — Ophthalmia  has  been  almost  entirely  ban- 
ished from  lying-in  hospitals  by  the  routine  employment 
of  prophylactic  treatment.  This  consists  in  bathing  the 
eyelids  immediately  after  the  head  has  escaped  from  the 


648  THE   NEW-BORN   CHILD 

vulva  with  an  antiseptic  lotion,  such  as  1  in  4,000  perchloride 
of  mercury,  and  the  subsequent  instillation  into  the  con- 
junctival sac  of  one  or  two  drops  of  a  1  per  cent,  solution  of 
nitrate  of  silver.  The  efficacy  of  silver  salts  in  destroying 
the  gonococcus  is  weU  known,  and  their  employment  in  this 
connection  is  of  course  a  prophylactic  for  this  organism  only. 
The  vegetable  salts  of  silver,  such  as  argyrol  and  protargol, 
are  not  so  efficient  in  prophylaxis  as  the  nitrate  of  silver. 
Ov/ing  to  the  difficulty  of  efficiently  treating  ophthalmia  in 
infants,  and  the  serious  risks  of  blindness  which  attend  it, 
the  use  of  this  prophylactic  in  all  suspicious  cases  is  to  be 
advised.  Some  disadvantages  attend  the  instillation  of  silver 
nitrate — viz.,  a  slight  conjunctivitis  is  often  set  up  by  the 
solution,  even  when  there  has  been  no  infection,  and  occar 
sionally  keratitis  ensues,  which  may  lead  to  corneal  opacities. 
Routine  anti-gonorrhoeal  prophylaxis  is  unnecessary  in 
private  practice,  but  it  would  of  course  be  indicated  by 
direct  evidence,  or  by  suspicion  of  gonorrhoea  in  the  mother. 

Active  treatment,  consists  chiefly  in  frequently  irrigating 
the  conjunctival  sacs  with  warm  saturated  boric  lotion  or 
saline  solution,  and  the  instillation  once  a  day  of  silver  nitrate 
or  protargol  solution.  The  highly  infectious  nature  of  the 
discharge  must  be  borne  in  mind,  and  the  child  must  accord- 
ingly be  put  in  the  charge  of  a  separate  nurse,  to  whom  the 
risk  both  to  herself  and  others  should  be  fully  explained. 
In  severe  cases  the  advice  of  an  ophthalmic  surgeon  should 
be  obtained. 

Icterus  Neonatorum.^ — Jaundice  occurs  in  the  new-born 
child  under  three  different  conditions  :  first,  it  may  be  due  to 
the  normal  heemolytic  changes  which  occur  in  the  liver  and 
other  organs  ;  secondly,  it  may  be  due  to  congenital  stenosis 
of  the  bile-ducts  ;  thirdly,  it  may  be  infective  and  due  to 
umbilical  sepsis  or  some  form  of  intestinal  intoxication.  The 
first  variety  is  unimportant  ;  it  is  most  marked  in  premature 
or  debilitated  infants,  and  disappears  spontaneously  without 
treatment ;  the  urine  does  not  contain  bile  acids  or  salts,  nor 
are  the  stools  decolorised.  The  second  and  third  varieties 
are  almost  necessarily  fatal  ;  the  third  is  sometimes  epidemic 
in  character. 

[  Gastro-intestinal  Haemorrhage  :    Melsena  Neonatorum.^ — ■ 
This  rare  but  serious  disease  of  the  new-born  child  probably 


HELENA  649 

occurs  in  about  1  in  1,000  births.  The  prominent  symptoms 
are  vomiting  of  blood,  and  the  passage  of  blood  in  the  stools  ; 
the  latter  varies  in  amount  from  a  microscopic  quantity 
up  to  a  steady  trickle  of  blood  through  the  anus.  The  gravity 
of  the  condition  is  shown  by  the  statistics  of  Townshend 
and  others,  the  mortality  being  approximately  50  per  cent. 

In  many  cases  the  first  symptom  is  haematemesis,  which 
may  occur  before  the  first  feed  has  been  given  ;  in  the 
majority  of  cases  the  initial  symptoms  appear  in  the  first 
forty-eight  hours  ;  after  the  first  week  very  few  cases  have 
been  recorded.  Slight  bleeding  per  anum  may  be  overlooked 
while  the  meconium  is  being  discharged,  unless  care  is  exer- 
cised. In  many  cases  the  bleeding  is  not  limited  to  the 
gastro -intestinal  canal,  but  other  mucous  surfaces  such  as 
the  mouth  and  nose  may  be  affected.  Not  infrequently 
subcutaneous  ecchymoses  also  occur.  The  effect  of  loss  of 
blood  on  the  young  infant  is  very  serious,  and  in  severe 
cases  the  child  dies  of  anaemia  within  two  or  three  days  of  the 
commencement  of  the  disease. 

The  causation  is  obscure,  but  from  a  careful  clinical 
study  Tyson  adduces  good  reasons  for  regarding  it  as  septic 
in  origin  ;  the  point  of  entrance  of  the  organisms  may  be  the 
cut  umbilical  cord,  or  an  abrasion  on  an  exposed  mucous 
surface,  for  example  in  the  mouth  or  nose.  Another  pos- 
sible point  of  entrance  may  be  the  small  intestine,  in  which 
mucous  erosions  may  be  formed  by  the  action  of  the  acid 
gastric  contents  when  feeding  and  digestion  first  begin.  A 
general  septic  toxaemia  is  not  infrequently  associated  with 
bleeding  under  varied  conditions. 

The  treatment  consists  mainly  in  supporting  the  infant's 
strength  with  subcutaneous  injections  of  normal  saline  ; 
the  amount  given  must  be  small — 1  to  2  ounces — and  very 
careful  antiseptic  precautions  must  be  observed.  Drugs 
are  of  little  use,  but  recent  attempts  at  treatment  with  blood 
serum  are  said  to  have  yielded  encouraging  results.  The 
earliest  attempts  were  made  with  horse  serum,  but  better 
effects  are  shown  by  serum  of  blood  drawn  from  the  umbilical 
cord  of  another  child  at  birth  ;  the  blood  of  an  adult  may 
be  used  if  none  other  is  available.  The  dose  is  10  c.c.  repeated 
three  times  a  day,  and  if  no  effect  is  produced  the  frequency 
of  the  dose  may  be  increased.     The  serum  acts  by  raising 


650  THE   NEW-BORN   CHILD 

the  coagulability  of  the  infant's  blood.     Feeding  should  be 
limited  to  the  whey-cream  mixture. 

Infantile  Syphilis. — The  early  recognition  of  infantile 
syphilis  is  of  such  importance  that  the  matter  must  be 
briefly  referred  to  ;  for  a  systematic  account  a  text-book  of 
Diseases  of  Children  should  be  consulted.  A  syphiUtic 
infant  is  often  premature,  and  even  when  born  at  term  is 
usually  under-sized.  The  skin  is  often  of  a  brownish  colour, 
and  wrinkled  from  deficiency  of  subcutaneous  fat  ;  some- 
times, however,  the  child  appears  to  be  quite  healthy  when 
born.  In  a  few  days  some  or  all  of  the  following  signs  may 
appear  :  (1)  skin-cracks  (rhagades)  at  the  corners  of  the 
mouth  ;  (2)  nasal  catarrh  (snuffling),  which  sooner  or  later  is 
accompanied  by  a  watery  discharge  ;  (3)  an  eruption  on  the 
buttocks,  at  first  dull  red  and  later  coppery  in  colour,  and 
tending  to  spread  in  a  papular  form  down  the  legs  ;  (4)  loss 
of  weight.  It  must  be  remembered  that  simple  nasal  catarrh 
from  cold  often  occurs  in  infants,  therefore  snuffling  does 
not  necessarily  indicate  syphilis  ;  and  the  eruption  on  the 
buttocks  at  first  resembles  that  due  to  diarrhoea.  Any 
combination  of  the  above  conditions  justifies  careful  inquiry 
for  syphilitic  taint  in  the  parents,  and  Wassermann's 
reaction  may  be  employed  to  confirm  the  clinical  diagnosis 
both  in  the  child  and  the  parents.  The  treatment  consists 
in  administering  grey  powder  in  doses  of  half  a  grain  twice  or 
three  times  a  day  ;  infants  tolerate  mercury  well,  and  rapid 
improvement  usually  follows.  The  signs  of  fcetal  syphilis 
have  been  already  mentioned. 


Part  VII 

OBSTETEIC    OPERATIONS 

Artificial  Interruption  of  Pregnancy 

It  may  be  necessary  or  advisable  to  interrupt  pregnancy 
either  before  the  foetus  is  viable  [induction  of  abortion)  or 
after  it  has  become  viable  {induction  of  premature  labour). 
We  shall  have  to  consider  first  the  indications  for  interrupt- 
ing pregnancy,  and  then  the  methods  by  which  it  may  be 
accomplished. 

A.     Indications  for  inducing  Abortion  or 
Premature  Labour 

I.  Induction  of  Abortion. — The  indications  may  be 
divided  into  two  groups — general  and  local. 

(A)  General  indications. 

(1)  Hyperemesis  gravidarumi. 

(2)  Acute   or  chronic   nephritis   with   a  history   of 

eclampsia  in  a  previous  pregnancy  ;   sometimes 
bacillus  coli  urinary  infection. 

(3)  Chronic    valvular    disease    of    the    heart    with 

failure  of  compensation. 

(4)  Advanced  pulmonary  phthisis. 

(5)  Insanity. 

(6)  Chorea  when  not  amenable  to  general  treatment. 

(B.)  Local  indications. 

(!)  Incarcerated  retroversion,  or  irreducible  pro- 
lapse, of  the  gravid  uterus. 

(2)  Extreme  degrees  of  obstruction,  when  the  alter- 
native of  Csesarean  section  at  term  is  refused 
by  the  patient— e.g'.  : 

{a)  Pelvic  contraction  of  extreme  degree  (see 
p.  418). 


652  OBSTETRIC   OPERATIONS 

(6)  Atresia  of  the  vagina  or  cervix. 

(c)  Irremovable  malignant  tumours,   such  as 

those  of  the  pelvic  bones,  and  advanced 

carcinoma  of  the  cervix. 

(3)  Hydatidiform  degeneration  of  the  chorion. 

(4)  '  Threatened     abortion '     with     uncontrollable 

haemorrhage. 

(5)  Acute  hydramnios. 

(6)  Retention  of  a  dead  ovum  (occasionally). 

Certain  of  the  conditions  enumerated  above  form  absolvte 
indications  for  the  induction  of  abortion  :  these  are  nephritis, 
uncompensated  valvular  lesions  of  the  heart,  advanced 
phthisis,  insanity,  irremovable  malignant  tumours,  hyda- 
tidiform mole,  uncontrollable  uterine  haemorrhage  and  acute 
hydramnios.  In  the  case  of  the  other  indications,  induction 
is  to  be  regarded  only  as  the  last  resort,  after  the  methods 
of  treatment  described  in  previous  sections  have  been  found 
unsuccessful. 

Criminal  Abortion. — It  must  be  recollected  that  the 
induction  of  abortion,  except  for  clear  medical  indications, 
is  an  offence  against  the  law,  and  is  punishable  by  imprison- 
ment. It  is  therefore  advisable,  before  inducing  abortion, 
that  a  consultation  should  take  place  between  two  medical 
men,  both  of  whom  accept  responsibility  for  what  is  to  be 
done.  Medical  men  are  sometimes  requested  by  married 
women  to  induce  abortion  because  pregnancy  is  inconvenient 
or  motherhood  expensive  ;  but  for  reasons  so  inadequate 
as  this,  the  operation  should  not  be  performed. 

II.  Induction  of  Premature  Labour. — Labour  may  be 
mduced  prematurely  with  two  distinct  objects  :  (1)  to  save 
the  mother  when  urgent  complications  are  present ;  (2)  to 
enable  the  foetus  to  pass  without  injury  through  a  relatively 
or  absolutely  narrow  pelvis. 

(A)  General  Indications. — Those  already  mentioned  as 
indications  for  inducing  abortion  will,  when  encountered  in 
late  pregnancy,  indicate  induction  of  premature  labour.  An 
important  addition  must  be  made — viz.,  eclampsia,  and  the 
toxaemic  state  which  precedes  it  in  cases  where  medical 
treatment  has  failed  ;  this  condition  is  very  seldom  met  with 
before  the  child  is  viable. 


INDUCTION   OF   ABORTION  653 

(B)  Local  indications. 

(1)  Ante-partum     haemorrhage,    when    profuse    or 

recurrent. 

(2)  Hydramnios,      when     attended     with     severe 

pressure-symptoms. 

(3)  Pelvic  contraction  of  moderate  degree. 

(4)  Abnormally    large    size    of    foetus    in    previous 

pregnancies. 

(5)  Premature  death  of  the  foetus  in  utero  in  previous 

pregnancies. 

(6)  Post-maturity.     Owing  to  the  large  size  of  the 

child  pregnancy  should  not  be  allowed  to  go 
beyond  300  days. 

Methods  of  Inducing  Abortion  and  Premature  Labour 

Many  different  methods  are  available  for  this  purpose  : 
the  choice  of  a  method  is  determined  partly  by  the  period  to 
which  |)regnancy  has  advanced,  and  partly  by  the  degree  of 
urgency  of  the  indication.  Methods  required  during  the 
earlier  months  of  pregnancy  are  not  suitable  for  the  latter 
months  ;  it  will  therefore  be  convenient  in  the  first  place  to 
consider  them  in  relation  to  the  period  of  pregnancy. 

During  the  First  Three  Months  of  Pregnancy. — During 
this  period  of  pregnancy  induction  of  abortion  may  become 
necessary  from  haemorrhage  (including  hydatidiform  degene- 
ration), or  from  some  serious  maternal  disorder,  such  as 
pernicious  vomiting,  nephritis,  or  cardiac  disease.  In  all 
such  conditions  it  is  desirable  to  employ  a  method  by  which 
the  uterus  can  be  rapidly  emptied  ;  slow  methods  of  abortion 
involve  increased  risks  of  septic  infection,  and  when  serious 
illness  is  present  more  harm  to  the  patient  than  rapid 
methods. 

The  best  method  is,  therefore,  rapid  dilatation  of  the 
cervix  under  anaesthesia,  and  immediate  evacuation  of  the 
uterus.  It  is  not  in  all  cases  an  easy  matter  to  dilate  the 
cervix  of  a  gravid  uterus,  and  the  preliminary  use  of  a 
laminaria  tent  may  be  of  considerable  assistance.  The 
tent  should  be  introduced  at  least  twelve  hours  before  the 
operation.  Scrupulous  attention  to  antiseptic  technique  is 
called  for  when  this  appliance  is  used.     The  tent  is  sterilised 


654  OBSTETRIC   OPERATIONS 

by  immersion  for  at  least  a  week  in  absolute  alcohol,  or  in 
1  in  1,000  alcoholic  solution  of  perchloride  of  mercury.  The 
vulva  should  be  shaved  and  the  vagina  and  vulva  swabbed 
with  an  antiseptic  solution — e.g.,  1  in  4,000  perchloride.  A 
duck-bill  speculum  is  then  passed,  the  cervix  seized  with  a 
vulsellum,  and  the  tent,  held  in  the  introducer,  carefully 
guided  into  the  cervical  canal  and  pushed  in  for  an  inch  and  a 
half— i.e.,  until  the  upper  end  has  passed  the  internal  os.  The 
largest  size  of  tent  which  it  is  thought  the  cervix  will  take 
should  be  selected.  The  effect  of  the  tent  is  partially  to 
dilate  the  cervix,  and  to  soften  its  tissues  so  that  the  subr 
sequent  stages  of  the  dilatation  can  be  carried  out  without 
laceration. 

After  the  patient  has  been  ansesthetised  the  tent  is 
removed,  and  the  cervix  dilated  to  the  fullest  possible  extent 
with  the  graduated  metal  dilators  shown  in  Fig.  93.  The 
operator  should  use  sterilised  rubber  gloves,  and  the  pro- 
cedure is  to  be  carried  out  in  the  same  manner  and  with  the 
same  precautions  as  the  gynaecological  operation  of  cervical 
dilatation.  In  this  manner  the  cervical  canal  may  be 
stretched  sufficiently  to  admit  the  index  finger  readily.  This 
is  quite  large  enough  for  the  removal  of  a  three  months' 
ovum  ;  at  the  fourth  or  fifth  month  it  may  be  necessary  to 
enlarge  the  cervical  canal  still  further  in  the  manner  described 
on  the  next  page. 

The  dilated  cervix  being  firmly  held  in  the  grip  of  one  or 
two  pairs  of  vulsellum  forceps,  the  index  finger  is  passed  into 
the  uterus,  the  half-hand  (fingers  only)  being  introduced  for 
this  purpose  into  the  vagina.  First  the  finger  is  used  to 
detach  the  ovum  from  the  uterine  wall ;  the  other  hand  is 
placed  upon  the  fundus  and  so  used  as  to  push  down  the 
uterine  waU  upon  the  finger  in  the  cavity,  bringing  the  upper 
part  within  reach.  The  attachments  of  the  ovum  at  this 
period  are  very  delicate,  and  are  readily  torn  through.  When 
the  ovum  has  been  completely  detached  the  finger  is  with- 
drawn and  a  pair  of  ovum  forceps  introduced  into  the  uterus  ; 
some  part  of  the  membranes  is  then  seized,  and  often  the 
entire  sac  can  be  gently  withdrawn  in  one  piece.  The  foetal 
tissues  are  very  soft  at  this  period,  and  there  is  no  difficulty 
in  extracting  the  foetus  in  the  same  manner.  Next,  the 
finger  should  be  again  introduced  and  the  walls  of  the  uterus 


INDUCTION   OF   ABORTION  655 

scraped  with  the  finger-tip  to  detach  the  decidua  vera  ;  or 
a  flushing  curette  may  be  gently  used  for  this  purpose.  The 
decidua  forms  a  thick  bulky  membrane  and  its  complete 
removal  is  a  matter  of  considerable  importance.  Finally, 
the  uterine  cavity  should  be  thoroughly  irrigated  with  a  hot 
solution  (110°  F.)  of  a  non-toxic  antiseptic,  such  as  lysol  or 
iodine,  which  serves  the  double  purpose  of  arresting  haemor- 
rhage and  removing  small  fragments  of  loose  tissue.  Finally, 
the  uterus  should  be  firmly  massaged  between  the  fingers 
in  the  vagina,  and  the  other  hand  on  the  abdomen  ;  this  will 
squeeze  out  excess  of  douche  fluid  and  will  cause  the  uterus 
to  contract  strongly,  arresting  all  haemorrhage.  Continuance 
of  undue  bleeding  is  usually  due  to  retention  of  a  piece  of 
membrane  or  blood-clot,  and  the  finger  should  be  re-intro- 
duced into  the  uterus  to  detect  it.  If  difficulty  is  still 
encountered  in  arresting  haemorrhage  the  uterine  cavity 
may  be  firmly  plugged  with  iodoform  or  plain  sterilised 
gauze,  and  an  intra-muscular  injection  of  ergot  or  pituitrin 
administered.  The  gauze  must  be  removed  within  twenty- 
four  hours. 

This  is  the  safest  and  simplest  method  of  terminating  an 
early  pregnancy,  and  no  special  operative  experience  is 
required. 

During  the  Second  Three  Months  of  Pregnancy. — During 
this  period  the  operation  required  for  rapidly  emptying  the 
uterus  is  more  severe  than  in  the  earlier  months  ;  alter- 
native procedures,  known  as  slow  methods,  may  be  practised, 
when  the  indication  is  not  one  of  urgency. 

Rapid  Method. — The  increased  difficulty  arises  mainly 
from  the  size  of  the  foetus  and  the  greater  density  of  its 
tissues  ;  the  cervical  canal  must  accordingly  be  further 
enlarged  to  allow  it  to  be  extracted. 

The  operation  j)roceeds  in  the  manner  just  described  up 
to  the  point  at  which  the  cervix  has  been  dilated  to  the 
fullest  possible  extent  with  the  graduated  metal  dilators. 
Further  than  this  the  cervix  cannot  safely  be  stretched  ; 
serious  laceration  almost  inevitably  results  from  attempts  to 
dilate  it  further.  It  is  accordingly  preferable  to  incise  the 
cervix  in  the  following  manner  :  The  cervix  firmly  held 
with  two  pairs  of  forceps  is  pulled  down  to  the  vulva  and  a 
transverse  incision  made  across  it,  about  two  inches  in  length, 


656 


OBSTETRIC   OPERATIONS 


at  the  level  of  the  cervico -vaginal  insertion — i.e.,  immediately 
below  the  bladder  (Fig.  292).  The  bladder  is  then  separated 
by  blmit  dissection  from  the  front  of  the  cervix  mitil  the 
peritoneum  of  the  floor  of  the  utero-vesical  pouch  can  be 


Pig.  292.- 


-The  Incision  across  the  front  of  the  Cervix  at  the  level 
of  the  Yaorinal  Insertion. 


reached  with  the  finger  and  recognised  by  the  slippery 
surfaces  ghding  over  one  another  (Fig.  293).  An  incision  is 
then  made  with  strong  scissors  through  the  anterior  wall  of 
the  cervix  in  the  middle  line,  beginning  below  and  contmued 


INDUCTION   OF  ABORTION 


657 


upwards  until  the  internal  os  has  been  reached  and  divided 
(Fig.  294).  By  carrying  the  incision  still  further  upwards 
the  amount  of  room  can  be  increased  according  to  the 
requirements  of  the  case.     The  membranes  are  now  ruptured 


hi  W 


i 


Fig.  293— Separation  of  the  Bladder  from  the  front  of  the  Cervix 
to  the  level  of  the  Utero-vesical  Pouch. 

and  the  foetus  seized  and  extracted  by  the  feet ;  the  head 
can  be  perforated  if  necessary  with  a  knife  or  scissors.  The 
placenta  and  membranes  can  now  be  detached  and  removed 
without  difficulty.  After  the  uterine  cavity  has  been  douched 
and  bleeding  checked  in  the  manner  described  above,  the 
E.M.  42 


658 


OBSTETRIC   OPERATIONS 


incisions  are  closed  with  catgut  stitches.  The  uterine  incision 
can  be  brought  well  into  view  by  drawing  down  the  cervix 
with  two  pairs  of  vulsellum  forceps,  while  an  assistant  pushes 
down  the  uterus  from  above.  Lastly,  the  edges  of  the 
vaginal  incision  are  closed  in  the  same  manner. 

This  operation  is  more  severe  and  requires  more  operative 


Fig.  294. — Division  of  the  Anterior  "Wall  of  the  Cervix  as  high  as 
the  level  of  the  Internal  Os.  The  bag  of  waters  is  seen 
bulging  through  the  internal  os ;  the  foetus  is  represented  in 
outline.  (The  fcetal  outline  is  too  lai'ge  for  the  period — 
three  to  six  months.) 


exjDerience  than  that  described  above.  It  is  precisely  the 
same  procedure  as  that  practised  by  gynaecologists  in 
removing  fibroid  polypi  too  large  to  pass  through  the  un- 
divided cervical  canal. 

Slow  Methods. — These  methods  differ  from  that  just 
described,  inasmuch  as  they  aim  at  exciting  the  uterus  to 
throw  off  its  contents  by  a  process  similar  to  that  of  spon- 


INDUCTION    OF   ABORTION 


659 


taneous  abortion.  It  is  in  many  cases  exceedingly  difficult 
to  excite  effective  uterine  contractions  ;  considerable  delay 
and  repeated  manipulations  are  then  required,  and  in  the 
end  some  operative  procedure  may  be  necessary  to  terminate 
the  process.  Thus  the  danger  of  the  occurrence  of  septic 
infection  is  much  increased. 

(1)  The  membranes  may  be  ruptured  by  the  sound  and 
dilatation  begun  by  the  use  of  a  laminaria  tent.  Rupturing 
the  membranes  will  not  start  labour  pains  unless  it  leads  to 
a  free  escape  of  liquor  amnii ;  a  gradual  escape  may  con- 
tinue  for  several   days   without  any  sign  of   labour  com- 


FlG.  295.— Small  Hydrostatic  Dilator  inflated  with  Fluid. 


mencing.  Tents  are  useful  in  softening  the  cervical  tissues 
and  producing  a  slight  amount  of  dilatation,  but  are  not 
effective  agents  for  exciting  uterine  contractions. 

(2)  A  better  method  is  the  use  of  the  small  hydrostatic 
bag  shown  in  Fig.  295  ;  if  the  cervix  is  completely  closed 
sufficient  enlargement  can  be  produced  by  the  preliminary 
use  of  a  tent,  or  by  using  uterine  dilators.  The  instru- 
ment consists  of  a  thin  rubber  bag  tied  over  the  end  of 
a  gum-elastic  catheter.  When  deflated,  it  can  be  pushed 
through  the  internal  os  on  the  catheter  without  difficulty. 
It  can  be  sterilised  by  boiling  before  being  introduced,  and 
inflated  by  injecting  a  measured  quantity  of  sterilised  water 
into  it  after  introduction.     It  then  lies,  as  shown  in  Fig.  296, 

42—2 


660 


OBSTETRIC   OPERATIONS 


in  the  lower  pole  of  the  uterine  cavity.  It  is  better  not  to 
rupture  the  membranes  before  using  this  dilator,  as  a  much 
more  definite  increase  in  intra-uterine  tension  can  then  be 
obtained.  The  bag  acts  in  the  same  manner  as  the  larger 
appliance  of  Champetier  de  Ribes  (see  p.  663).     Graduated 


Fig.  296. — The  small  Hydrostatic  Dilator  in  position  in  the  Uterus. 


sizes  can  be  obtained,  and  when  one  bag  has  been  expelled 
as  the  cervix  dilates,  another  can  be  introduced. 

As  soon  as  regular  contractions  set  in  the  case  may  be 
managed  as  one  of  spontaneous  abortion. 

During  the  third  three  months. — During  this  period  the 
large  size  of  the  foetus  and  the  comparative  density  of  its 
bony  tissues  render  the  evacuation  of  the  uterus  a  much 
longer  and  more  complicated  process.     It  is  advisable,  in 


INDUCTION   OF   LABOUR  661 

all  but  cases  of  the  greatest  urgency,  to  proceed  by  methods 
designed  to  excite  the  process  of  labour,  which  is  then  con- 
ducted upon  general  principles,  and  in  many  cases  may  pro- 
ceed to  a  natural  termination  without  further  interference. 
In  the  presence  of  maternal  complications  which  admit  of 
no  delay,  such  as  eclampsia  and  certain  cases  of  ante-partum 
haemorrhage,  forcible  methods  of  rapid  delivery  jper  vaginam 
may  be  adopted  [accouchement  force),  or  the  classical  opera- 
tion of  Ceesarean  section  may  be  practised. 

The  methods  applicable  to  this  period  will  now  be 
described  in  turn,  and  the  conditions  indicated  for  which 
each  is  suitable. 

Rupture  of  the  Membranes. — If  this  procedure  is  so  carried 
out  as  to  lead  to  the  escape  of  a  large  quantity  of  liquor 
amnii,  labour  follows  rapidly  as  a  rule.  The  slow  escape  of  a 
small  amount  of  fluid  may  not  provoke  labour  for  several 
days.  Loss  of  a  considerable  proportion  of  the  liquor 
amnii  has  a  very  unfavourable  influence  on  the  course  of 
labour  (see  p.  453),  while  the  opening  up  of  the  amniotic 
sac  permits  of  an  ascending  infection  reaching  the  uterus  from 
the  vagina.  These  two  objections  have  led  to  other  methods 
being  preferred  to  this  one  in  the  majority  of  cases.  In 
severe  instances  of  hydramnios  it  is,  however,  the  method  of 
choice,  and  offers  obvious  advantages. 

Intra-uterine  Bougie  (Krause's  method). — This  procedure 
consists  in  the  introduction  of  one  or  more  sterilised  gum- 
elastic  bougies  into  the  uterus,  between  the  membranes  and 
the  uterine  wall  ;  it  is  a  very  simple  method,  and  requires 
only  care  and  surgical  cleanliness  in  its  performance.  The 
maternal  passages  must  be  healthy,  and  should  be  previously 
sterilised,  as  far  as  possible,  by  repeated  douching.  The 
observance  of  strict  antiseptic  precautions  is  facilitated  by 
introducing  the  bougies  under  anaesthesia.  The  bougies  can 
be  sterilised  by  boiling  them  for  ten  minutes  ;  a  convenient 
plan  is  to  place  three  or  four  bougies  in  a  glass  catheter  tube 
furnished  with  a  rubber  stopper  and  an  outer  metal  case. 
The  tube  containing  the  bougies  is  placed  unstoppered  in  a 
steriliser  and  boiled  along  with  the  rubber  stopper.  The 
tube  can  then  be  removed,  and  the  rubber  stopper  inserted 
with  the  tube  full  of  the  boiled  water,  without  exposing  or 
touching  the  bougies.     In  this  way  sterilised  bougies  can  be 


662 


OBSTETRIC   OPERATIONS 


carried  in  the  instrument  bag  with  safety  (Fig.  297).  Boiling 
has  the  practical  disadvantage  of  making  the  bougies  so 
pliable  that  it  is  difficult  to  introduce  them.  This  may  be 
overcome  by  using  a  stilette  when  passing  them.  Or,  as  an 
alternative  to  boiling,  the  bougies  may  be  immersed  for  an 
hour  in  1  in  500  formalin  solution.  This  solution  does  not 
roughen  and  corrode  the  gum  elastic  material  as  do  carbolic 
acid  and  the  mercurial  solutions.  The  usual  size  employed  is 
No.  10  or  No.  12,  but  larger  sizes  up  to  No.  18  can  be  used 
with  safety.  The  introduction  of  the  bougie  will  be  facili- 
tated by  placing  the  patient  on  her  back  with  the  legs 
acutely  flexed — the  modified  lithotomy  position.  After 
disinfection  of  the  vulva  and  vagina,  and  the  hands,  the 
cervix  is  exposed  with  Sim's  speculum,  seized  with  vulsellum 
forceps,  and  carefully  swabbed  with  tincture  of  iodine  ; 
the  point  of  the  bougie  is  then  guided  directly  into  the  cervix, 


Fig.  297.— Glass  Tube,  Eubber  Stopper,  and  Metal  Case  for  carrying 
Sterilised  Bougies. 

and  pushed  up  to  the  level  of  the  internal  os.  The  point 
is  then  directed  towards  the  uterine  wall  and  the  bougie 
slowly  pushed  up  into  the  uterus.  The  length  of  the  bougie 
which  can  thus  be  passed  depends  of  course  on  the  size  of  the 
uterus — i.e.  the  period  of  pregnancy  ;  at  or  near  term  only 
about  one  inch  will  remain  below  the  os  externum.  It  is 
well  to  introduce  a  second  bougie  by  the  side  of  the  first.  The 
vagina  should  then  be  lightly  plugged  with  iodoform  gauze. 
Sometimes  a  little  bleeding  occurs  indicating  that  the  edge 
of  the  placenta  has  been  reached  ;  this  does  no  harm.  The 
bougie  is  often  pushed  through  the  membranes  ;  but  when 
this  happens  only  a  moderate  amount  of  liquor  amnii 
escapes  if  the  puncture  is  above  the  level  of  the  internal  os. 
If  any  resistance  to  the  advance  of  the  bougie  is  met  with, 
the  placenta  may  be  in  the  way  or  the  membranes  adherent ; 
the  bougie  should  then  be  withdrawn,  and  re-introduced  in 
a  different  direction. 

This  procedure  invariably  provokes  labour,  but  the  time 


KRAUSE'S   METHOD  663 

of  onset  of  labour  pains  is  very  variable.  If  the  bougie  is 
made  to  perforate  the  membranes  so  that  a  certain  amount 
of  fluid  escapes  the  effect  is  more  rajjidly  produced.  It  is 
in  common  use  at  Queen  Charlotte's  Hospital,  where  it  is 
found  that  the  average  interval  between  the  introduction  of 
the  bougie  and  the  delivery  of  the  child  is  seventy-five 
hours  ;  occasionally  labour  may  be  completed  in  twelve 
hours,  but  cases  have  now  and  then  occurred  in  which 
eight  to  ten  days  have  elapsed.  Even  if  labour  pains  do 
not  come  on,  a  little  dilatation  of  the  cervix  sufficient  to 
admit  one  or  two  fingers  is  usually  produced  in  twenty-four 
to  forty-eight  hours.  The  bougies  should  not  be  removed 
when  the  pains  begin,  for  this  may  cause  labour  to  cease ; 
they  come  away  spontaneously  with  the  after-birth.  If 
there  is  no  sign  of  the  commencement  of  labour  in  twenty- 
four  hours,  another  bougie  should  be  introduced  at  the 
opposite  side  ;  a  fourth  may  be  put  in  after  a  further 
twenty-four  hours  if  required.  A  better  plan  is  to  rupture 
the  membranes  when  the  cervix  has  been  softened  and 
dilated  sufficiently  to  introduce  two  fingers,  and  introduce 
the  small  de  Ribes's  bag. 

Krause's  method  is  simple  and  easy,  and  is  accordingly 
well  suited  for  general  use.  If  due  attention  is  paid  to 
surgical  cleanliness,  bougies  may  remain  for  several  days  in 
the  uterus  and  no  harm  will  result.  They  usually  become 
very  soft  after  forty-eight  hours'  maceration  in  the  uterus. 
If  the  membranes  are  accidentally  ruptured  during  their 
introduction,  it  is  little  if  any  disadvantage  if  the  opening  so 
made  is  above  the  cervix  ;  for  the  escape  of  fluid  through  this 
valvular  opening  is  slow,  and  a  small  bag  of  waters  is  formed 
notwithstanding.  The  disadvantage  of  the  method  is  the 
uncertainty  as  to  when  labour  will  begin  effectively. 

Hydrostatic  Dilators. — Dilatation  of  the  cervix  by  the 
introduction  into  the  uterus  of  rubber  or  silk  bags,  and  their 
forcible  distension  with  water,  is  a  method  which  has  been 
much  in  vogue  for  many  years.  The  small  bags  used  for 
inducing  abortion  have  been  already  described  ;  only  one 
other  need  be  referred  to — viz.,  that  of  Champetier  de  Ribes  ; 
the  principles  upon  which  its  action  is  based  will  become  clear 
when  the  instrument  and  the  method  of  using  it  have  been 
described. 


664 


OBSTETRIC   OPERATIONS 


De  Ribes's  dilator  is  a  curved  pyriform  bag,  cylindrical 
on  transverse  section,  and  made  of  strong  silk,  covered  with 
indiarubber  or  gutta-percha  (Fig.  298)  ;  it  is  therefore 
impervious  and  inelastic,  it  preserves  its  shape  when  dis- 
tended, and  can  be  sterilised  by  boiling.  The  broad  upper 
end  measures,  when  fully  distended  in  the  two  sizes  usually 
supplied  commercially,  4|  inches  and  3|  inches  in  diameter  ; 
the  curve  enables  it  to  lie  accurately  in  the  axis  of  the  pelvic 
canal.  When  in  position  the  broad  end  lies  in  the  lower 
uterine  segment,  above  the  level  of  the  pelvic  brim,  the  low^er 
end  protrudes  from  the  vulva  (Fig.  299).  To  this  end  is 
attached  a  rubber  tube,  through  which  fluid  can  be  pumped 


Fig.  298.^ — Cliampetier  de  Eibes's  Hydrostatic  Bag. 


into  the  bag,  and  a  tajj  to  retain  it  there.  It  is  not  advisable 
to  distend  the  bag  to  its  utmost  capacity  with  water,  as  it 
then  becomes  very  rigid  :  it  is  sufficient  to  introduce  into 
the  larger  size  about  fourteen  ounces,  into  the  smaller  about 
eleven  ounces.  It  cannot  be  passed  through  the  undilated 
cervix  ;  if  the  cervix  admits  one  finger,  the  bag  can  be  intro- 
duced under  an  anaesthetic  ;  if  it  admits  two  fingers,  an 
anaesthetic  is  not  always  required,  but  it  is  of  advantage  in 
allowing  greater  attention  to  antiseptic  details.  Therefore, 
when  used  to  induce  labour,  it  may  be  necessary  to  dilate  the 
cervix  partially  by  some  other  method,  such  as  the  use  of 
graduated  metal  dilators,  for  which  an  anaesthetic  is  of 
course  always  necessary. 

The  bag  must  first  be  sterilised  by  boiling  for  ten  minutes  ; 


INDUCTION   OF   LABOUR 


665 


it  should  be  filled  with  water  and  the  tap  left  oj)en  before 
being  placed  in  the  steriliser,  so  that  the  boiling  water  can 
circulate  through  it  and  sterilise  it  both  inside  and  out. 
Then  it  is  immersed  in  a  solution  of  1-4,000  biniodide  of 
mercury  if  not  used  immediately.  The  genital  passages  must 
be  douched  and  swabbed,  and  the  operator's  hands  carefully 


Fig.  299. — De  Bibes's  Dilator  introduced  into  the  Uterus.     (Edgar.) 


sterilised.  The  bag  is  then  rolled  up  into  the  smallest 
possible  bulk  and  held  in  a  pair  of  sterilised  forceps  ;  special 
forceps  may  be  obtained  with  curved  blades  (Fig.  300),  but 
an  ordinary  pair  of  ovum  forceps  will  serve  the  purpose 
equally  well.  Two  fingers  of  the  left  hand  are  used  to  guide 
the  forceps  into  the  cervical  canal,  and  the  broad  base  of  the 
bag  is  then  pushed  up  well  above  the  level  of  the  internal  os. 
The  forceps  is  then  withdrawn,  and  boracic  lotion  (1  in  40), 


666  OBSTETRIC   OPERATIONS 

or  boiled  water,  pumped  into  the  bag  with  a  syringe  ;  the 
capacity  of  the  bag  should  have  been  previously  measured, 
and  a  quantity  of  fluid  less  than  that  requked  to  fill  it 
entnely  should  be  injected.  If  the  bag  has  not  been  pushed 
far  enough  into  the  cervix,  it  will  escape  into  the  vagina  as 
it  becomes  distended  ;  if  the  broad  end  lies  above  the  internal 
OS,  its  shape  will  prevent  its  escape  in  this  manner. 

De  Ribes's  bag,  as  a  rule,  is  introduced  between  the 
membranes  and  the  uterine  wall ;  when  distended  it  there- 
fore causes  extensive  separation  of  the  membranes  from  the 
wall  of  the  lower  uterine  segment.  If,  however,  while 
introducing  it  the  membranes  should  be  accidentally 
ruptured,  no  harm  will  foUow,  for  the  distended  bag  prevents 
escape  of  the  liquor  amnii.  An  important  exception  to  this 
rule  is  the  case  of  placenta  preevia  ;    here  the  membranes 


Fig.  300. — De  Eibes's  Forceps. 

should  first  be  ruptured  and  the  bag  then  introduced  into 
the  amniotic  sac,  otherwise  distension  of  the  bag  will  cause 
extensive  separation  of  the  placenta,  which  not  only  increases 
the  risk  of  haemorrhage,  but  also  prejudices  the  survival  of 
the  child  by  diminishing  its  sources  of  aeration  and  nutrition. 
The  normal  mechanism  of  labour  is  closely  imitated  by 
the  action  of  de  Ribes's  bag.  Its  curved  conical  shape 
corresponds  to  the  shape  of  the  dilating  cervix  and  lower 
uterine  segment,  while  its  fluid  consistence  resembles  that 
of  the  normal  dilator — the  bag  of  waters.  When  the  mem- 
branes have  ruptured,  escape  of  liquor  amnii  is  prevented 
by  it.  Its  action  depends  upon  its  exciting  uterine  contrac- 
tions, by  which  it  is  driven  gradually  down  through  the 
cervix,  distending  it  as  it  passes.  When  the  pains  excited 
by  it  are  feeble,  dilatation  can  be  assisted  by  traction  on 
the  lower  end  of  the  bag.  Traction  may  be  applied  inter- 
mittently by  pulling  during  the  pains,   or  continuously  by 


Induction  of  labour  ee? 

attaching  a  weight  of  two  to  four  pounds  to  the  end  of  the 
rubber  tube  and  carrying  it  over  the  foot  of  the  bed.  Ulti- 
mately the  whole  cervical  canal  is  stretched  to  the  diameter 
of  the  broad  end,'  and  any  intra-uterine  manipulation 
required  to  deliver  the  child  can  therefore  be  immediately 
undertaken.  When  the  broad  end  has  been  driven  out  of 
the  cervix  the  contents  may  be  allowed  to  escape  and  the 
bag  is  then  withdrawn.  Often  the  uterine  pains  excited  by 
it  are  so  strong  that  natural  delivery  is  quickly  effected 
after  dilatation,  when  the  pelvis  is  of  normal  size.  Some- 
times, however,  the  pains  rapidly  cease  when  the  dilator  has 
been  expelled  into  the  vagina.  In  some  rare  cases  pains  are 
not  excited  by  the  bag  at  all,  although  with  the  hel]D  of  trac- 
tion it  may  dilate  the  cervix. 

The  time  occupied  by  this  method  in  fully  dilating  the 
cervix  varies  ;  when  employed  to  excite  labour  it  takes, 
on  an  average,  from  twelve  to  twenty-four  hours  to  obtain 
full  dilatation  ;  if  labour  is  already  in  progress  dilatation 
may  be  completed  by  its  use  in  from  half  an  hour  to  two 
hours. 

Two  objections  to  the  use  of  de  Ribes's  bag  must  be 
noticed.  In  the  first  place,  there  is  no  doubt  that  its 
presence  in  the  lower  uterine  segment  displaces  the  present- 
ing part  and  may  thus  disturb  a  favourable  presentation. 
This  objection  is,  however,  unimportant,  for  after  the  bag 
has  done  its  work  the  condition  of  the  passages  allows  of 
the  easy  correction  of  any  unfavourable  presentation. 
The  occasional  occurrence  of  rupture  of  the  uterus  when  the 
bag  has  been  used  in  cases  of  placenta  prsevia  has  been 
already  referred  to. 

In  inducing  premature  labour  with  de  Ribes's  bag  the 
larger  size  is  usually  unnecessary  ;  and  it  must  be  recollected 
that  when  the  pelvic  brim  is  much  contracted  there  will  not 
be  room  in  the  conjugate  for  the  larger  size.  De  Ribes's 
bag  is  too  large  to  be  used  for  the  induction  of  abortion,  the 
small  rubber  bags  previously  described  being  preferable  for 
this  purpose. 

Dilatation  by  Branched  Metal  Dilators. — This  method, 
introduced  by  Bossi  in  1887,  has  been  described  in  pre- 
vious editions,  but  extended  experience  of  its  use  has 
been    unfavourable,  and  it  is   now  regarded    as   too  dan- 


668  OBSTETRIC   OPERATIONS 

gerous  for  general  use.  Xo  description  of  it  need  therefore 
be  given. 

Digital  Dilatation  of  the  Cervix. — When  the  cervix  is 
sufficiently  dilated  to  admit  one  or  two  fingers,  full  dilatation 
may  be  f)i'oduced  bj^  digital  stretching.  The  greatest 
attention  must  be  paid  to  antiseptic  technique,  sterilised 
rubber  gloves  beuig  worn  b}^  the  operator,  and  the  vulva  and 
vaginal  canal  being  thoroughl}^  cleansed  and  swabbed  with 
antiseptic  solutions.  The  thumb  and  index  finger  of  one 
hand  are  first  inserted,  and  the  cervix  stretched  as  far  as 
possible  by  separating  them.  Then  the  remainmg  fingers 
are  successively  introduced,  until  all  the  fingers  of  the  hand 
can  be  passed  through  the  internal  os  ;  this  involves  the 
passage  of  the  entire  hand  into  the  vagina.  Another  method 
in  which  both  hands  are  employed  is  also  used  ;  after  two 
fingers  of  one  hand  have  been  passed,  the  corresponding 
fingers  of  the  other  hand  are  introduced,  and  the  cervix 
stretched  by  separating  the  fingers  of  the  two  hands. 

This  method  requires  an  anaesthetic,  careful  antiseptic 
precautions,  and  the  exercise  of  gentleness  and  great  patience 
in  its  performance  ;  even  then  very  serious  lacerations  of  the 
vaginal  vault  or  of  the  cervix  runnhig  up  into  the  lower 
segment,  and  even  complete  rupture  of  the  uterine  wall, 
may  occur,  for  it  is  impossible  to  graduate  the  amount  of 
force  applied  m  this  manner.  It  is  consequently  not  to  be 
recommended  as  a  method  of  inducing  labour,  but  it  may 
safely  and  convenienth^  be  employed  under  anaesthesia  to 
complete  dilatation  ui  cases  of  prolonged  first  stage  when 
the  cervix  is  already  at  least  one-haK  dilated. 

Vaginal  Ccesarean  Section. — This  operation  consists  in 
deeply  incising  the  cervix  so  as  to  aUow  of  the  immediate 
dehvery  of  the  child  through  thenatm-al  passages.  Although 
anticipated  by  French  obstetricians  of  the  eighteenth  cen- 
tury, the  operation  here  described  is  of  quite  recent  date, 
and  was  introduced  m  1896  by  Diihrssen. 

The  operation  is  performed  as  follows  by  Bumm.  -The 
cervix  is  first  exposed  b}^  two  specula,  then  seized  with  two 
pairs  of  vulsellum  forceps,  and  pulled  down  to  the  level 
of  the  ostium  vaginae.  A  median  incision  is  then  made, 
commencing  on  the  anterior  Up  of  the  os  externum,  and  pass- 
ing over  the  cervix  and  forwards  on  to  the  anterior  vaginal 


VAGINAL   CESAREAN   SECTION  669 

wall  to  a  point  two  inches  above  the  urinary  meatus.  Through 
this  incision  the  bladder  is  separated  from  the  uterine  and 
vaginal  walls  by  blunt  dissection.  The  peritoneum  of  the 
utero-vesical  pouch  is  pushed  up,  but  is  not  incised.  A  median 
incision  is  then  made  in  the  anterior  wall  of  the  cervix  and 
carried  upwards  to  the  level  of  the  internal  os  ;  the  cervix 
can  be  pulled  down  lower  and  lower  during  the  process  so 
as  to  keep  the  whole  incision  well  within  view.  When  the 
internal  os  has  been  incised  the  bag  of  membranes  will 
present.  Diihrssen  recommends  that  when  the  foetus  is  at 
term  the  posterior  fornix  should  be  similarly  incised  and  the 
posterior  cervical  wall  divided  up  to  a  corresponding  level.  The 
uterine  incision  is  carried  a  little  above  the  internal  os,  and 
then  the  membranes  are  ruptured,  and  dehvery  effected 
by  podalic  version.  The  uterine  incision  measures  about 
4  inches,  so  that  it  involves  both  cervix  and  lower  uterine 
segment.  After  delivery  of  the  placenta,  the  cervix  is 
again  pulled  down  to  the  vulva  and  the  deep  incision  closed 
with  interrupted  catgut  sutures  from  above  downwards. 
Finally  the  incision  in  the  vaginal  wall  is  similarly  closed. 

This  operation  is  difficult  in  a  primigravida  on  account  of 
the  small  size  of  the  vagina  and  the  rigidity  of  the  perineum. 
It  cannot  be  performed  unless  the  maternal  pelvis  is  of 
normal  size,  and  up  to  the  present  time  it  has  been  chiefly 
applied  to  cases  of  eclampsia  in  which  it  was  desired  to  deliver 
rapidly.  The  mortality  is  high,  but  it  must  be  recollected 
that  the  maternal  conditions  for  which  it  is  undertaken  are 
very  grave.  There  is  no  doubt  that  at  or  near  term  the 
operation  is  one  of  much  greater  difficulty  than  the  classical 
Csesarean  section,  and  it  is  very  doubtful  whether  it  has  any 
advantages  which  compensate  for  these  technical  difficulties. 
If  pregnancy  has  not  exceeded  the  twenty-eighth  week, 
and  the  patient  is  a  multipara  the  operation  is  compara- 
tively simple. 

By  Munro  Kerr  and  other  writers  the  operation  of 
division  of  the  cervix  to  facilitate  evacuation  of  the  uterus 
in  the  middle  three  months  of  pregnancy  is  also  called  Vaginal 
Csesarean  Section.  But  in  earlier  pregnancy  the  procedure, 
though  similar  in  principle,  is  characterised  by  great  sim- 
plicity, while  in  the  case  of  a  viable  child  it  becomes  a  for- 
midable operation,  requiring  special  technical  skill ,     It  is  an 


670  OBSTETRIC   OPERATIONS 

innovation  to  ajijoly  tlie  term  Csesarean  Section  to  incision 
of  the  uterus  at  a  time  when  the  child  is  non- viable,  and  it  is 
better  to  restrict  the  name  of  Vaginal  Csesarean  Section  to 
the  oj)eration  just  described. 

Accouchement  force. — This  procedure  is  defined  by  Munro 
Kerr  as  '  rapid  and  forcible  enlargement  of  the  cervical 
canal  and  immediate  extraction  of  the  child.'  It  therefore 
includes  the  methods  of  digital  dilatation,  dilatation  with  the 
branched  dilatators  of  Bossi,  &c.,  and  vaginal  Caesarean 
section.  These  are  all  operations  of  great  gravity,  and  are 
attended  by  risks  of  serious  injury  to  the  maternal  passages, 
and  a  correspondingly  high  maternal  mortality.  Further, 
they  cannot  be  made  use  of  when  pelvic  contraction  is  present, 
if  it  is  desired  also  to  save  the  life  of  the  child.  By  British 
obstetricians  these  methods  are  seldom  employed.  Cases  in 
which  the  immediate  evacuation  of  the  uterus  becomes  neces- 
sary owing  to  some  urgent  maternal  complication  are  by 
preference  dealt  with  by  the  classical  operation  of  Csesarean 
section.  In  comparison  with  the  procedures  classed  under 
Accouchement  force,  Caesarean  section  is  simpler,  requires 
less  technical  skill,  is  equally  expeditious,  and  is  applicable 
to  all  conditions. 

General  Considerations. — Slow  methods  of  induction  are 
suitable  for  non-urgent  indications,  such  as  pelvic  con- 
traction, albuminuria  and  nephritis,  chorea,  heart  disease, 
&c.  Cases  of  ante-partum  haemorrhage,  with  the  exception 
of  the  concealed  accidental  form,  may  also  be  dealt  with 
by  these  methods.  The  simplest  is  the  intra-uterine  bougie 
method  of  Krause  ;  the  sole  disadvantage  attending  it  is 
the  delay  which  often  occurs  in  the  establishment  of  effective 
uterine  contractions.  This  delay  may  be  greatly  shortened 
by  removing  the  bougies  and  introducing  the  smaller  de 
Ribgs's  bag  as  soon  as  sufficient  dilatation  of  the  cervix  to 
aUow  of  this  being  easily  done  is  produced  ;  this  usually 
occurs  in  twenty-four  to  forty-eight  hours,  even  if  labour  is 
not  actually  excited. 

De  Ribes's  bag  is  the  best  method  to  employ  to  provoke 
labour  in  cases  of  placenta  prsevia  ;  if  the  cervix  is  insuffi- 
ciently dilated  the  small  hydrostatic  dilator  (Fig.  295)  may 
first  be  used,  in  order  to  j)roduce  sufficient  dilatation  to 
allow  of  the  introduction  of  the  larger  bag. 


TURNING  671 

Version  :    Turning. 

Version  consists  in  altering  the  presentation  of  the  foetus 
in  the  uterus  ;  this  may  be  done  in  order  to  correct  an 
unfavourable  presentation,  or  for  other  purposes  which  will 
be  referred  to  below.  As  a  rule  the  breech  is  made  to  present 
{podalic  version),  sometimes,  however,  it  is  the  head  {cephalic 
version).  The  conditions  under  which  it  may  be  desirable 
to  change  the  presentation  are  various,  and  this  is  true  also 
of  the  purposes  which  it  is  intended  to  effect. 

(1)  In  transverse  cases  it  is  essential  that  the  presenta- 
tion should  be  changed  (see  p.  382)  ;  before  labour,  cephalic 
version  is  to  be  recommended ;  during  labour,  podalic 
version,  followed  by  pulling  down  a  leg. 

(2)  In  breech  presentations  seen  before  labour  or  early 
in  labour  cephalic  version  should  be  performed  if  the  patient 
is  a  primipara. 

(3)  In  brow  presentations  seen  early  in  labour  podalic 
version  is  indicated. 

(4)  In  placenta  praevia  podalic  version  is  extensively 
employed,  partly  as  a  means  of  immediately  controlling 
hsemorrhage,  partly  to  expedite  delivery. 

(5)  In  prolapse  of  the  cord  podalic  version  may  be 
performed  if  the  head  is  not  engaged,  to  relieve  the  cord 
from  the  risk  of  compression  by  the  head. 

(6)  In  cases  of  pelvic  contraction  of  the  fiat  variety  and 
of  medium  degree,  prophylactic  podalic  version  may  be 
employed,  as  some  authorities  believe  that  the  passage  of 
the  after-coming  head  is  easier  in  this  kind  of  pelvis  than  the 
fore-coming  head. 

(7)  When  the  cervix  is  three-fourths  dilated  and  the  pelvis 
of  normal  size,  podalic  version  may  be  practised  as  a  method 
of  immediate  delivery  when  this  is  indicated  by  maternal 
complications  or  by  foetal  distress. 

Version  may  be  performed  by  external  (abdominal) 
manipulations  alone,  by  internal  manipulations  alone,  or 
by  combined  internal  and  external  manipulations  ;  these 
methods  are  respectively  termed  external,  internal,  and 
combined  or  bi-polar  version. 

External  Version. — The  foetus  in  utero  can  be  turned  by 
abdominal  manipulation  if  there  is  a  sufficiency  of  liquor 


672 


OBSTETRIC   OPERATIONS 


amnii,  if  the  uterus  is  not  contracting  frequently  and  power- 
fully, and  if  the  abdominal  walls  are  lax.  The  time  for  its 
performance  is  therefore  before  labour  sets  in,  or  very  early 
in  labour  ;  it  is  much  easier  in  a  multipara  than  in  a  primi- 
gravida.  Full  surgical  angesthesia  is  required  if  strong  and 
frequent  labour  pains  are  present.  It  is  the  method  of  choice 
in  all  cases  of  transverse  presentation  seen  before  labour  ; 


Fig.  301. — External  Version  in  Breech  Presentation.  First  Stage.  The 
hands  are  locating  the  position  of  the  head ;  the  head  and  breech  are 
to  be  pushed  aside  in  opposite  directions,  as  shown  by  the  arrows. 


it  is  also  useful  in  breech  presentations  occurring  in  a 
primipara  and  first  seen  before  labour.  In  both  of  these 
instances  cephalic  version  should  be  performed — i.e.  the 
head  should  be  made  to  present.  It  may  also  be  made  use 
of  in  placenta  prsevia  at  the  beginning  of  the  first  stage,  as  a 
preliminary  to  pulling  down  a  leg  into  the  cervix. 

(a)  Head  or  Breech  Presentation. — -The  patient  should  lie 
on  her  back  with  the  shoulders  slightly  raised  and  the  knees 


VERSION 


673 


flexed,  the  abdomen  being  completely  uncovered.  The 
position  of  the  head  should  first  be  located  ;  it  will  usually 
be  found  in  a  breech  presentation  distinctly  to  one  side  of 
the  mid-line  (Fig.  301).  The  breech  will  be  found  as  a  rule 
lying  above  the  brim  ;  if  labour  is  in  progress  and  the  mem- 
branes have  ruptured  it  may  be  engaged. 

The  first  stage  consists  in  applying  pressure  to  the  head 
and  to  the  breech  with  the  hand  in  opposite  directions,  so  as 


Fig.  302. — External  Version.     The  presentation  is  transverse,  the  first 
stage  having  been  completed. 

to  push  the  head  down  towards  the  pelvis  and  the  breech 
upwards  upon  the  opposite  side  of  the  uterus  towards  the 
fundus  (Fig.  301).  The  effect  of  this  movement  is  to  make 
the  presentation  transverse.  If  the  abdominal  walls  are  lax 
as  in  a  multipara,  and  the  patient  is  not  in  labour,  this  stage 
is  very  readily  carried  out  ;  in  the  case  of  a  primipara, 
if  labour  is  in  progress,  considerable  difificulty  may  be 
encountered,  and  it  may  be  necessary  to  give  an  anaesthetic. 
The  second  stage  continues  the  movement  begun  in  the 
E.M.  43 


674 


OBSTETRIC   OPERATIONS 


first  until  the  head  has  been  brought  over  the  pelvic  brim 
and  the  breech  pushed  up  to  the  fundus  (Fig.  303).  The 
head  must  now  be  carefully  adjusted  in  the  brim  and  the 
long  axis  of  the  foetal  trunk  made  to  correspond  with  the 
long  axis  of  the  uterus.  Unless  this  point  receives  careful 
attention  recurrence  of  the  displacement  will  almost  cer- 
tainly take  place. 

The  third  stage  consists  first  in  pushing  the  head  down  into 
the  brim  as  low  as  possible  by  grasping  it  mth  the  two  hands 
(Fig.  304).     FmaUy,  steady  pressure  is  made  upon  the  fundus 


Fig.  303. — External  Version.  Second  Stage.  The  lie  of  the  fcetus  has 
been  made  longitudinal  and  the  head  is  being  adjusted  over  the  pelvic 
brim,  while  the  breech  is  being  pushed  into  the  mid-line  at  the  fundus. 


SO  as  to  push  the  whole  foetal  bodj^  as  low  down  in  the  abdo- 
men as  possible.  This  has  the  effect  of  flexing  the  spine  and 
the  head,  the  object  being  to  restore  the  normal  attitude  of 
general  flexion  as  nearly  as  possible,  for  this  attitude  may 
have  been  disturbed  by  the  previous  manipulations. 

Transverse  Presentation. — 'V\'Tien  a  transverse  presenta- 
tion is  met  with,  the  possibility  of  the  pehds  being  con- 
tracted must  always  be  borne  in  mind,  and  careful  measure- 
ments must  be  taken.  If  the  degree  of  contraction  is  com- 
patible mth  delivery  fer  vaginam,  podahc  version  may  be 
performed  if  the  pelvis  is  flattened.     The  position  of  the 


VERSION 


675 


head  should  be  carefully  located,  and  the  operation  is  then 
performed  in  the  manner  above  described,  except  that  the 
head  is  pushed  upwards. 

After  correction  by  external  version  the  original  presenta- 
tion is  apt  to  recur.  In  transverse  presentations  and  in 
placenta  prsevia  podalic  is  preferable  to  cephalic  version,  and 
if  labour  has  begun  the  membranes  may  be  ruptured  and  a 
foot  pulled  down  into  the  vagina.     This  effectually  prevents 


Fig.  304. — External    Version.     Third  Stage.     The  head  is  heing  pushed 
down  into  the  pelvic  brim,  a  A'ertex:presentation  having  been  produced. 

recurrence  of  the  displacement.  If  cephalic  version  has  been 
performed  for  breech  presentation  before  labour,  great 
difficulty  may  be  encountered  in  keeping  the  head  in  the 
pelvis,  and  the  operation  may  have  to  be  repeated.  If 
labour  has  begun,  a  thickly  folded  towel  may  be  laid  on  each 
side  of  the  uterus  and  a  tight  binder  applied  over  all,  to 
assist  in  maintaining  the  corrected  presentation. 

Internal  Version. — This  operation  consists  in  introducing 
the  hand  into  the  uterine  cavity,  seizing  the  feet  and  turning 
the  child  so  as  to  bring  down  the  pelvic  extremity  ;    under 

43—3 


676 


OBSTETRIC   OPERATIONS 


urgent  conditions  this  is  followed  by  immediate  extraction, 
but  if  the  circumstances  permit,  time  should  be  allowed  for 
natural  delivery  to  take  place  as  in  the  management  of  a 
breech  labour.     Internal  version  is  a  very  old  obstetric  pro- 


FiG.  305. — Effect  of  seizing  the  Lower  Leg  in  turning  a 
Transverse  Presentation  ;  the  back  is  rotated  to  the 
front.     (Faraboeuf  and  Varnier.) 


cedure,  and  was  described  and  practised  by  Hippocrates  ; 
later  writers  upon  obstetrics  also  have  practically  all  de- 
scribed it  (Celsus,  Galen,  Ambroise  Pare,  Baudelocque, 
Smellie),  so  that  it  has  probably  been  in  unbroken  use  for 
two  thousand  years.  The  earlier  records  of  the  operation 
show  that  it  was  then  used  to  bring  down  the  head  (cephalic 


VERSION 


677 


version)  ;  withm  recent  times  it  has  been  employed  only  as 
a  method  of  podalic  version.  This  method  of  version  differs 
from  the  others  in  providing  not  only  for  changing  the 
presentation,  but  also  for  immediately  delivering  the  child. 


Fig.  306. — Effect  of  seizing  the  Lower  Leg  in  tiu'ning  a  Trans- 
verse Presentation.     (Faraboeuf  and  Yarnier.) 


The  operation  is  by  no  means  devoid  of  risk,  and  should  not 
be  performed  except  under  perfectly  clear  indications.  It 
is  absolutely  contra-mdicated  by  tonic  uterme  contraction  ; 
and  whenever  some  time  has  elapsed  since  rupture  of  the 
membranes  it  should  not  be  attempted  unless  the  mobility 


678 


OBSTETRIC   OPERATIONS 


of  the  foetus  is  good,  and  the  hand  can  be  introduced  without 
force  into  the  uterus.  When  the  foetus  is  dead,  craniotomy 
should  always  be  preferred.  Unless  the  conjugate  diameter 
of  the  pelvic  brim  measures  at  least  3|  inches,  version  is  an 
unsuitable  method  of  delivering  a  living  child  in  a  flat  pelvis, 


Fig.  307. — Effect  of  seizing  the  Upper  Leg  in  turning  a 
Transverse  Presentation  ;  the  back  is  rotated  posteriorly. 
(Faraboeuf  and  Varnier.) 

and  in  all  degrees  of  generally  contracted  pelvis  it  should  be 
avoided.  The  strictest  antiseptic  precautions  are  called  for, 
and  the  manipulations  must  be  carried  out  with  gentleness 
and  deliberation  ;  only  in  this  way  can  the  risks  of  sepsis  and 
rupture  of  the  uterus  be  reduced  to  a  minimum.  The  most 
favourable  moment  for  performance  of  the  operation  is  when 
the  cervix  is  about  three-fourths  dilated  and  the  membranes 


VERSION 


679 


are  unruptured  ;  but,  when  half  dilated,  the  cervix  can  first 
be  stretched  to  the  required  extent  by  the  digital  method, 
under  anaesthesia. 

The  most  important  part  of  the  procedure  consists  in 


Fig.  308. — Effect  of  seizing  the  Upper  Leg  in  turning  a 
Transverse  Presentation.     (Faraboeuf  and  Varnier.) 

seizing  and  pulling  down  a  foot  ;  it  is  usually  better  to  pull 
down  one  foot  only  and  complete  the  extraction  as  a  half 
breech.  In  cases  where  rapidity  is  desired  both  feet  may  be 
pulled  down  at  the  same  time,  or  the  second  may  be  sought 
for  after  the  first  has  been  pulled  down. 

The  first  point  requiring  attention  is  that  the  hand  should 


680 


OBSTETRIC   OPERATIONS 


not  be  mistaken  for  the  foot.  The  great  mobihty  of  the 
thumb  is  of  course  distinctive  of  the  hand  ;  but  it  is  not 
always  easy  to  recognise  this  when,  for  example,  the  limb 


Fig.  309. — Effect  of  seizing  the  Upper  Leg  in  turning  a 
Transverse  Presentation.     (Faraboeuf  and  Varnier.) 


can  only  be  reached  with  the  finger  tips.  As  Munro  Kerr 
has  pointed  out,  the  most  distinctive  part  of  the  foot  is  the 
heel,  which  can  be  recognised  by  one  finger,  and  serves 
absolutely  to  distinguish  it  from  the  hand.  If  this  point 
caiuiot  be  made  out,  the  fingers  should  be  passed  up  to  the 


VERSION  681 

buttocks  and  drawn  down  the  thigh  and  leg  until  the  foot  is 
reached. 

The  next  point  is  the  choice  of  a  foot,  which  is  important, 
inasmuch  as  although  either  will  do,  extraction  is  greatly 
facilitated  by  selecting  the  proper  foot.  The  principle 
governing  the  choice  is  that  that  foot  should  be  seized 
which,  when  drawn  down,  will  cause  the  back  of  the  child 
to  rotate  forwards  ;  if  the  wrong  one  is  seized  the  back 
will  rotate  backwards.  The  rule  is  that  in  transverse 
presentations,  when  the  position  is  dorso-anterior,  the 
lower  foot  should  be  pulled  down,  when  dorso-posterior, 
the  upper  foot.  From  Figures  305  to  309  it  will  be  seen 
that  the  direction  in  which  the  trunk  rotates  is  controlled 
by  the  choice  of  a  foot  when  one  only  is  pulled  down. 
As  the  dehvery  of  a  breech  presentation  is  much  easier 
when  anterior  rotation  of  the  back  occurs,  it  is  impor- 
tant that  the  proper  foot  should  be  pulled  down.  In  head 
presentations  the  choice  of  a  foot  is  unimportant,  as  dorso-' 
anterior  positions  necessarily  become  dorso-posterior  after 
turning.  In  seeking  the  proper  foot  it  must  be  recollected  that 
in  the  normal  foetal  attitude  the  legs  are  often  crossed  ;  in  a 
transverse  presentation  it  accordingly  follows  that  the  foot 
first  encountered  is  not  necessarily  that  of  the  lower  limb.  In 
order  to  be  sure  the  fingers  must  be  passed  up  to  the  buttocks 
and  the  desired  foot  found  by  following  down  the  thigh. 

Preliminaries. — An  anaesthetic  should  always  be  ad- 
ministered, for  should  the  patient  move  unexpectedly  while 
the  operator's  hand  is  in  the  uterus  the  risks  of  rupture  are 
considerable.  The  bladder  should  be  emptied  by  catheter. 
The  position  of  the  back  and  head  of  the  child  should  be 
carefully  localised  by  abdominal  and  vaginal  examination, 
and  the  foetal  heart  auscultated.  The  approximate  size  of 
the  pelvis  and  of  the  foetus  must  also  be  estimated.  The 
patient  may  be  placed  in  either  the  lithotomy  position  or 
the  ordinary  lateral  posture  ;  in  the  latter  less  assist- 
ance is  required  by  the  operator.  The  operator,  after  care- 
fully disinfecting  his  hands  and  forearms,  should  put  on  a 
pair  of  previously  boiled  rubber  gloves  ;  the  vulva  should  be 
shaved,  and  the  vulva  and  vagina  cleansed  with  soap,  and 
then  swabbed  with  an  antiseptic  solution  (biniodide  of 
mercury  1  in  1,000,  or  lysol  5J.  to  Oj.). 


682 


OBSTETRIC   OPERATIONS 


Stejps  of  the  Operation. — (a)  When  the  presentation  is 
transverse. — When  the  head  lies  to  the  right  the  patient 
should  be  placed  on  her  left  side,  with  the  buttocks  over  the 
edge  of  the  bed,  the  operator  using  his  right  hand  for  the 
internal  manipulations,  as  this  hand  can  be  more  easily 
directed  to  the  left  side  of  the  uterus  where  the  feet  are  lying 
(Fig.  310).     When  the  head  lies  to  the  left  side,  the  patient 


Fig.  310. — Internal  Version  for  Transverse  Presentation  ;  introducing  the 
hand  into  the  uterus.     (Aiter  Nagel.) 

should  be  placed  on  her  right,  the  operator  using  his  left 
hand. 

(1)  The  hand  should  be  passed  into  the  vulva  with  the 
fingers  and  thumb  bent  into  the  shape  of  a  cone  (Fig.  258)  ; 
the  direction  to  be  taken  is  at  first  upwards  and  backwards 
(axis  of  outlet),  gradually  changing  to  upwards  and  forwards 
(axis  of  brim). 

(2)  The  hand  should  not  enter  the  uterus  until  the  strong 
contractions  and  expulsive  efforts  excited  by  its  introduction 
into  the  vagina  have  passed  away. 

(3)  In  dorso-anterior  positions  the  hand  should  follow 


VERSION 


683 


the  curve  of  the  lower  buttock  and  thigh  until  the  lower  foot 
can  be  reached,  the  external  hand  raising  the  pelvic  pole  of 
the  foetus  so  as  to  render  it  more  accessible  (Fig.  311). 

(4)  In  dorso-posterior  positions  the  hand  should  be 
passed  over  the  ventral  aspect  of  the  foetus,  so  as  to  reach 
the  upper  foot,  aided  by  the  external  hand.  The  effect  of 
seizing  the  upper  foot  will  be  to  rotate  the  trunk  so  as  to 


Fig.  311. — Internal  Version  for  Transverse  Presentation  ;  seizing  the 
lower  foot.     (After  Nagel.) 

bring  the  back  forwards  and  convert  the  presentation  into 
an  anterior  breech. 

(5)  When  the  foot  has  been  seized,  it  should  be  drawn 
gently  down  into  the  vagina,  the  head  being  at  the  same  time 
pushed  up  towards  the  fundus  by  the  external  hand  or  by  an 
assistant  (Fig.  312).  The  patient  may  now  be  placed  in  the 
dorsal  position  (as  in  the  figure),  or  delivery  may  be  com- 
pleted without  change  of  position.  Extraction  is  usually 
easier  in  the  dorsal  position. 


684 


OBSTETRIC   OPERATIONS 


(6)  These  manipulations  should  as  far  as  possible  be 
made  during  the  intervals  of  the  contractions,  the  internal 
hand  making  no  advance  during  the  pains,  but  being  held 
flattened  over  the  body  of  the  child. 

(7)  The  next  step  is  the  extraction  of  the  child.     This 


Fig.  '612. — Internal  Version  ;  pulling  the  leg  down  through 
the  vulva,  and  pushing  the  head  upwards  with  the 
other  hand.     (After  Xagel.) 


must  be  carried  out  in  the  manner  already  described  in  the 
management  of  a  breech  labour  (see  p.  368).  The  risks  of 
the  arms  becoming  extended  are  great,  for  the  attitude  of  the 
foetus  is  necessarily  disturbed  in  turning.  Sometimes  in 
transverse  cases  an  arm  may  be  found  prolapsed  before 


VERSION 


685 


version  has  been  commenced.  A  loop  of  gauze  bandage 
should  then  be  passed  over  the  wrist,  and  sufficient  traction 
made  upon  it  to  prevent  this  arm  from  being  carried  up  into 
the  uterus  as  the  child's  body  is  turned.  If  the  other  arm 
should  become  extended  it  will  be  brought  down  much  more 
easily  than  if  both  were  extended.  Steady  pressure  on  the 
fundus  should  be  kept  up  by  an  assistant  during  extraction. 


Fig.  313. — Internal  Version  for  Vertex  Presentation  ;  introducing  the  liand 
into  the  uterus.     (After  Nagel.) 

(8)  After  the  delivery  of  the  after-birth  an  antiseptic 
intra-uterine  douche  should  always  be  given. 

(9)  Owing  to  the  risks  of  foetal  asphyxia,  preparations  for 
the  resuscitation  of  the  infant  should  be  made. 

(6)  When  the  head  presents. — In  non-engagement  of  the 
head  in  the  pelvic  brim,  prolapse  of  the  cord,  in  cases  of  ante- 
partum hsemorrhage,  or  in  presentation  of  the  face  or  brow, 
internal  version  of  a  head  presentation  during  labour  is 
sometimes  called  for.  Whenever  possible  it  is  preferable  to 
turn  by  the  external  method,  and  then  pull  down  the  legs 
(p.  501).      When   the   back   lies   to  the  right   the  patient 


686  OBSTETRIC   OPERATIONS 

should  be  placed  upon  her  left  side,  the  operator  using  his 
right  hand  ;  when  the  back  lies  to  the  left,  she  should  be 
placed  upon  her  right  side,  the  operator  using  his  left  hand 
(Fig.  313).  The  steps  of  the  operation  are  the  same  as  in  a 
transverse  presentation,  the  hand  being  always  passed  along 
the  ventral  aspect  of  the  foetus  ;  it  does  not  matter  in  this 
case  which  foot  is  seized  in  turning.  When  the  hand  enters 
the  uterus  the  head  is  necessarily  pushed  to  one  side,  thus 
facihtating  its  displacement  upwards  by  the  external  hand 
later  on.  It  is  more  difficult  to  turn  a  head  than  a  trans- 
verse presentation,  as  the  long  axis  of  the  foetus  must  be 
made  to  cross  the  transverse  axis  of  the  uterus.  It  follows 
that  this  method  of  dehvery  in  head  presentation  must  not 
be  attempted  unless  the  conditions  are  quite  favourable — 
and  sufficient  liquor  amnii  remains  in  the  uterus  to  allow 
free  mobility  to  the  presenting  part. 

Difficulties  in  Performing  Internal  Version. — ^Under 
favourable  conditions  internal  version  is  a  simple  and  an  easy 
operation  ;  but  the  extraction  of  the  child  after  it  has  been 
turned  may  be  comphcated  by  the  arms  becoming  extended. 
When  the  membranes  have  been  ruptured  for  some  time  and 
the  amount  of  Hquor  amnii  remaining  in  the  uterus  is  small, 
turning  is  both  difficult  and  dangerous.  It  is  sometimes 
difficult  to  decide  whether,  in  a  given  case,  it  is  safe  to  make 
the  attempt  or  not.  These  difficulties  are  most  often 
encountered  m  transverse  presentations  when  the  child  is 
still  alive.  The  presence  of  a  well-marked  retraction  rmg 
always  contra-indicates  any  attempt  at  version  ;  when  the 
natural  intermittent  character  of  the  uterine  contractions  has 
been  lost,  or  the  uterus  does  not  become  properly  relaxed 
during  the  intervals,  the  introduction  of  the  hand,  even  under 
full  anaesthesia,  excites  violent  expulsive  efforts  which  greatly 
impede  the  manipulations  and  increase  the  risks  of  rujDture. 
Unless  the  operator  has  had  some  previous  experience  of 
turning,  he  should  not  make  the  attempt  when  the  con- 
ditions are  not  in  all  respects  favourable. 

The  risks  which  attend  internal  version  are  clearly 
defined.  First,  there  is  the  risk  of  sepsis  ;  even  if  the 
hand  of  the  operator  is  protected  by  a  sterilised  rubber 
glove,  the  danger  of  carrjdng  infective  material  from  the 
vulva  into  the  uterus  reraains.     It  is  therefore  important 


VERSION     .  687 

that  special  precautions  should  be  taken,  the  vulva  being 
shaved,  and  both  vulva  and  vagina  carefully  cleansed  with 
soap,  followed  by  lysol  or  biniodide  of  mercury.  Douching 
alone  is  quite  inadequate.  Secondly,  there  is  the  risk  of 
rupture  of  the  uterus,  but  except  in  the  cases  of  difficulty  just 
referred  to,  this  risk  is  remote.  Thirdly,  version  having  been 
begun  and  the  foetus  partially  turned,  it  may  be  found 
impossible  to  complete  the  operation  owing  to  powerful  and 
continuous  retraction  of  the  uterus.  Fourthly,  version 
having  been  completed,  difficulty  in  extracting  the  after- 
coming  head  and  arms  may  be  met  with,  resulting  in 
the  death  of  the  child  from  asphyxia,  or  in  injury  to  its 
limbs. 

Combined  or  Bi-polar  Version.  (Method  of  Braxton 
Hicks.) — During  the  first  stage  of  labour,  when  the  cervix 
is  sufficiently  dilated  to  admit  one  or  two  fingers,  and  the 
membranes  are  unruptured,  or  if  ruptured,  a  large  amount  of 
liquor  amnii  remains,  it  is  possible  to  turn  without  intro- 
ducing the  hand  into  the  uterus.  It  is  evident  that  in 
internal  version  both  external  and  internal  manipulations 
are  employed,  and  both  poles  of  the  foetus  are  displaced  ;  it 
might  therefore  also  be  accurately  called  combined  or  bi- 
polar version.  The  essential  difference  between  internal 
version  and  the  method  now  to  be  described  is  that,  as  in 
the  latter  the  whole  hand  is  not  introduced  into  the  uterus, 
it  can  be  performed  at  an  earlier  stage  of  labour.  It  is  not 
frequently  performed,  for  it  is  more  difficult  than  either  of 
the  other  methods,  special  difficulty  being  met  with  in 
carrying  the  long  axis  of  the  foetus  through  the  transverse 
axis  of  the  uterus.  In  transverse  it  is  easier  than  in  vertex 
presentations.  Bi-polar  version  is  only  used  to  produce  a 
breech  presentation. 

Preliminaries. — These  are  the  same  as  for  internal 
version  ;  an  anaesthetic,  though  not  essential,  is  of  great 
assistance. 

Steps,  (a)  When  the  presentation  is  transverse. — Either 
hand  may  be  employed  for  the  internal  manipulations,  the 
patient  being  in  the  dorsal  or  left  lateral  position. 

(1)  The  position  of  the  head  having  been  located,  the 
presenting  shoulder  is  pushed  upwards  out  of  the  brim,  and 
towards  the  side  where  the  head  lies ;    the  external  hand 


688 


OBSTETRIC   OPERATIONS 


assists  by  piisliing  the  head,  iip^varcls  towards  the  hvpo- 
chondrium. 

(2)  The  arm  or  some  part  of  the  trunk  now  lies  over 
the  internal  os.  and  is  pushed  into  the  ihac  fossa  on 
the  same  side,  the  head  bemg  simultaneously  displaced 
upwards  and  towards  the  middle  line  into  the  epigastric 
region. 

(3)  The  breech  or  lower  hmbs  now  come  within  reach  of 

the  internal  fingers  ;  the 
membranes  are  then  rup- 
tured, and  one  foot  pulled 
down  mto  the  vagina,  while 
the  head  is  pushed  up  to 
the  fundus.  The  case  is 
then  managed  as  a  breech 
labour,  deliA^ery  being  left 
to  nature. 

(6)  When  the  head  pre- 
sents.— (1)  The  head  is 
pushed  upwards  out  of  the 
brim,  and  then  into  the 
ihac  fossa  07i  the  side  to 
which  the  hack  of  the  foetus 
lies  (Fig.  31-1)  ;  at  the  same 
time  the  breech  is  displaced' 
doA^nLwards  and  to  the  op- 
posite side. 

(2)  The  presentation 
has  now  become  transverse, 
or  oblique,  and  the  opera- 
tion is  completed  in  the 
maimer  just  described. 

It  is  seldom  necessary  to 
adopt  this  difficult  method 
of  version.  Under  most  circumstances  when  it  could  be  made 
use  of  it  will  be  fomid  easier  to  turn  by  the  external  method, 
and  havmg  thus  brought  down  the  breech  mto  the  brim,  to 
pass  two  fingers  into  the  cervix,  rupture  the  membranes  and 
pull  down  a  leg.  ^^^len  m  cases  of  placenta  prasvia  it  is 
desired  to  turn,  external  podahc  version  followed  by  imme- 
diate pulling  down  of  a  leg  is  preferable  to  the  method  of 


Fig.  314. — Bi-polar  Version  : 

First  Step  in  Head  Presentation. 

Placenta  Prtevia.     (Braxton  Hicks.) 


FORCEPS 


689 


Braxton  Hicks,  inasmuch  as  it  reduces  the  internal  manipu- 
lations to  a  minimum. 


Obstetric  Forceps 

The  construction  of  the  modern  obstetric  forceps  will  be 
best  understood  by  tracing  the  various  phases  through  which 
the  instrument  has  passed  in  its  evolution . 

The  earliest  forceps  to  be  publicly  described  was  that  of 
Palfjm.,  a  surgeon  of  the  city  of  Ghent,  in  1720.     It  consisted 


Fig.  315. — Different  Patterns  of  Chamberlen's  Forceps. 

of  a  pair  of  spoon-shaped  blades  with  wooden  handles  ;  the 
blades  were  applied  to  the  sides  of  the  head,  and  the  handles 
tied  firmly  together  so  that  the  instrument  could  be  used  for 
traction.  Before  this  period  (seventeenth  century),  an 
instrument  had  been  used  in  London  by  a  family  of  doctors, 
including  at  least  three  generations,  named  Chamberlen  ; 
the  construction  of  their  forceps  was,  however,  maintained 
as  a  strict  family  secret,  and  not  until  long  after  the  death  of 
the  last  of  their  line  did  the  secret  leak  out.  In  1813  the 
three  forceps  represented  in  Fig.  315  were  found  by  accident 
in  an  old  chest  in  a  house  which  one  hundred  years  previously 
had  belonged  to  the  Chamberlens,  and  are  believed  to  be  the 
E.M.  44 


690 


OBSTETRIC   OPERATIONS 


instruments  with  which  they  worked.  These  three  forceps 
were  distinctly  better  than  Palfyn's  ;  they  consisted  of  a 
pair  of  metal,  spoon-shaped,  fenestrated  blades,  united  like 


Fig.  316.— Short  or  Straiglit  Forceps. 

a  pair  of  scissors  with  a  pin- joint,  and  having  curved  scissors- 
handles  ;  slight  modifications  in  shape  appear  in  the  three 
forms,  and  in  one  a  tape  threaded  through  and  around  the 
blades  replaces  the  pin-jomt.     They  are  composed  of  three 


Fig.  317. — Straight  Forceps  applied  to  the  Head  at  the  Brim  (Schematic). 

(Milne  Murray.) 

a,  6.  Axis  of  pelvic  brim,     c,  i.  Plane  of  pelvic  brim,     c,  d.  Axis  of  pelvic  outlet, 
c,  X,  f.  Direction  of  traction  made  by  forceps. 

parts  :  (1)  the  curved  blade,  (2)  the  lock  or  joint,  and  (3)  the 
handle  ;  the  curve,  being  designed  to  adapt  the  blades  to 
the  foetal  head,  is  known  as  the  foetal  or  cephalic  curve.  This 
is  the  only  curve  upon  these  early  instruments  ;  viewed  m 
profile,  they  are  straight  from  end  to  end. 


FORCEPS 


691 


A  forceps  constructed  upon  this  principle,  and  called  the 
short  or  straight  forceps,  was  used  for  some  purposes  until 


Fig.  318. — Obstetric  Forceps,  showing  the  Cephalic  and  Pelvic 
Curves.     (Edgar.) 

comparatively  recent  years,  but  has  now  been  generally 
abandoned  (Fig.  316). 

The  faults  of  this  forceps  are  easily  demonstrated.  The 
instrument  is  straight,  but  the  pelvic  canal,  in  which  it  has 
to  lie,  is  curved  ;  therefore,  in  grasping  the  fcetal  head  at  the 
brim,  a  central  grip  cannot  be  ob- 
tained, for  the  instrument  will  seize 
the  part  of  the  head  which  lies  behind 
the  centre  (Fig.  317).  In  occipito- 
anterior positions,  traction  thus 
applied  to  the  sincipital  end  of  the 
head  would  induce  extension.  And 
further,  in  making  traction,  a  great 
deal  of  the  force  will  be  misapplied  ; 
for  while  the  head  must  travel  down- 
wards and  backwards  in  the  line  of 
the  axis  of  the  brim  (Fig.  317  a,  h), 
the  direction  of  traction  exerted  by 
the  forceps  is  in  a  line  (e,  x,  /)  in- 
termediate between  this  and  the 
axis  of  the  outlet  (c,  d).  A  great 
deal  of  force  will  therefore  be  lost, 

and  the  soft  parts  crushed  which  lie  between  the  head  and 
the  pubes.  The  misdirection  of  force  is  represented  by 
the  '  angle  of  error,'  b,  x,  f.  The  application  of  this  instru- 
ment to  the  head  in  the  pelvic  cavity  is  also  open  to  objection, 

44—2 


Fig.  319.— The  Double 
Slot  (English)  Lock, 
and  Shanks. 


692 


OBSTETRIC   OPERATIONS 


for  it  cannot  be  made  to  travel  in  any  part  of  the  pelvic  axis 
without  loss  of  much  of  the  force  applied. 

The  first  observer  who  attempted  to  remedy  the  faults  of 


Pig.  320. — Long  or  Curved  Obstetric  Forceps. 

the  straight  forceps  was  Levret,  of  Paris  (1751),  who  curved 
the  blades  forwards,  so  that  they  would  lie  accurately  in  the 
curve  of  the  pelvic  canal  (Fig.  320)  :  this  second  curve  has 
become    known   as    the   maternal   or   'pelvic   curve.     Minor 


Fig.  321. — Long  Forceps  applied  to  the  Head  at  the  Brim, 
(^lilne  Murray.) 

a,  &.  Axis  of  pelvic  brim,    e,  i.  Plane  of  pelvic  brim, 
f ,  ;)',  /.  Direction  of  traction  made  by  forceps. 

modifications  were  made  about  the  same  period  by  a  Scottish 
doctor  practising  in  London  named  Smellie,  who  invented 
the  double-slot  lock,  now  used  in  aU  British  forceps,  and 
introduced  between  the  blade  and  the  lock  a  straight 
portion,  2|  inches  long,  named  the  shank,  which  increased 


FORCEPS 


693 


the  length  of  the  instrument  so  that  the  operator  could  lock 
it  outside  the  vulva  when  applied  to  the  head  at  the  brim 
(Fig.  319).  The  result  of  these  alterations  was  thus  to 
lengthen  the  forceps  and  add  the  pelvic  curve.  This  instru- 
ment is  now  known  as  the  long  or  curved  forceps.  As  con- 
structed at  the  present  day  it  is  made  entirely  of  metal,  so 
that  it  can  be  boiled.  The  total  length  of  the  instrument 
is  15  inches  ;  the  cephalic  curve  of  the  blade  has  a  radius  of 
4|  inches,  and  allows  a  maximum  separation  in  the  centre  of 
3 1  inches,  with  a  minimum  separation  at  the  points  of  1  inch  ; 
the  pelvic  curve  has  a  radius  of  7  inches. 

The  great  advantage  of  the  pelvic  curve  is  that  it  enables 
the  forceps  to  obtain  a  central  grip  of  the  head,  which  does 


Fig.  322. — Milne  Murray's  Axis-traction  Forceps. 


not  disturb  its  attitude  ;  but  as  in  the  case  of  the  straight 
forceps  there  is  great  misdirection  of  the  line  of  traction 
(compare  Figs.  317  and  321).  The  direction  of  traction 
exerted  by  the  instrument  is  represented  by  a  line  joining 
the  handles  with  the  centre  of  the  fenestrum  (Fig.  321  e,  x,f). 
This  line  does  not  pass  through  the  centre  of  the  pelvis  at  all, 
but  lies  entirely  in  front  of  it  when  the  instrument  is  applied 
to  the  head  at  the  brim  ;  its  direction  also  diverges  widely 
from  the  axis  of  the  brim.  The  misdirection  of  force  is 
represented  by  the  angle  b,  x,  f.     ^ 

The  long  forceps  received  a  further  important  modifica- 
tion at  the  hands  of  Tarnier,  of  Paris,  in  1877.  This  observer 
first  introduced  the  principle  of  axis  traction — i.e.,  he  modified 
the  instrument  so  that  at  whatever  level  the  head  may  lie, 
traction  may  be  accurately  applied  to  it  in  the  axis  of  the 


694 


OBSTETRIC   OPERATIONS 


pelvis,  thus  enabling  all  the  force  exerted  to  be  employed  in 
the  most  advantageous  manner.  This  he  did  by  adapting  to 
the  ordinary  long  forceps  used  in  France  a  pair  of  curved 
metal  rods  by  which  traction  could  be  made,  known  as  the 
axis-tradion  rods.  There  are  a  number  of  points  of  difference 
between  the  French  and  English  obstetric  forceps  which 
need  not  be  described,  but  Tarnier's  mvention  was  applied 
in  1880  to  the  EngUsh  forceps  by  Sir  Alexander  Simpson. 


Fig.  323. — ;Axis-traction  Forceps  apj^lied  to  the  Head  at  the  Brim. 

(Milne  Murray.) 

a,  b.  Axis  of  pelvic  brim  coiuciding  with  line  of  traction. 

Simpson's  instrument  was  further  modified  and  improved  by 
jNIilne  Murray. 

The  axis-traction  forceps  of  Milne  Murray  is  shown  in 
Fig.  322.  The  traction  rods  are  attached  by  a  slot  at  the 
base  of  the  f  enestrum  on  each  side  :  they  are  curved  so  as  to 
lie  in  accurate  contact  with  the  lower  ends  of  the  blades  and 
the  shanks  ;  opposite  the  lock  they  are  curved  away  from  the 
handles,  and  connected  together  at  their  ends  with  an  easily 
worked  attachment.  The^ends  of  the  traction  rods  lie  about 
3^  inches  from  the  handles.  To  the  ends  when  united  is 
attached  a  transverse  bar  moving  on  a  ball-and-socket  joint, 
with  which  traction  can  be  made.  As  the  handles  of  the 
blades  are  only  used  in  applying  the  instrument,  and  are  not 
grasped  when  making  traction,  a  screw  is  attached  to  them 


FORCEPS 


695 


by  which  the  grip  of  the  blades  upon  the  head  can  be  retained. 
This  is  known  as  the  '  fixation  screw  '  ;  it  is  not  intended  to 
produce  compression  of  the  head,  but  simply  to  retain  the 
grip  of  the  blades  when  traction  is  being  made.  The  handles 
themselves  are  made  much  lighter  than  in  the  ordinary  long 
forceps,  and  may  be  conveniently  distinguished  as  the 
'  application  '  handles,  the  transverse  bar  attached  to  the 
traction    rods    being    called    the    '  traction '    handle.     The 


/   // r,  I  Axis  of    pelvic 

(ij  /  bri-m 


Plane  of  pelvic 
brim 


Fig.  324. — Axis-traction  Forceps  applied  to  the  Head  in  the 
Pelvic  Cavity.     (Simpson.) 

'tnoU. — The  line  of  traction  is  represented  a  little  in  front  of  its  true  position. 

traction  rods  and  handle  are  detachable,   and  the  whole 
instrument  can  be  sterilised  by  boiling. 

When  this  forceps  is  applied  to  the  head  at  the  brim, 
traction  made  with  the  traction  handle  will  cause  the  head  to 
descend  in  the  axis  of  the  brim  so  long  as  the  traction  rods 
are  kept  in  contact  with  the  shanks  (Fig.  324).  The  direction 
of  the  force  applied  is  represented,  in  all  positions  of  the 
instrument,  by  a  straight  line  running  from  the  point  of 
application  of  the  force  (traction  handle)  through  the  centre 
of  the  fenestrum  ;  when  the  head  is  at  the  brim,  this  line 
coincides  exactly  with  the  axis  of  the  brim  (Fig.  323)  ;  when 


696 


OBSTETRIC   OPERATIONS 


the  head  is  in  the  pelvic  cavity,  it  coincides  with  the  axis  of 
the  cavity  at  the  level  occupied  by  the  head  (Fig.  324) — i.e.,  a 
line  intermediate  between  the  axis  of  the  brim  and  the  axis 
of  the  outlet.  As  long  as  the  traction  rods  are  kept  in  con- 
tact with  the  shanks,  the  Line  of  traction  will  always  corre- 
spond with  the  axis  of  that  part  of  the  pelvis  in  which  the 
head  Hes  ;  and  in  pulling  the  head  through  the  pelvis  the 
application  handles  will  be  observed  to  incline  more  and 
more  to  the  front  as  the  head  descends  (see  Figs.  332  and  333). 


Pig.  325. — Pajot's  Manoeuvre.* 

It  foUows  that  none  of  the  force  applied  is  wasted,  for  the 
angle  of  error  {b,  x,f)  seen  in  the  case  of  the  short  forceps  and 
the  ordinary  long  forceps  has  entirely  disappeared  (compare 
Figs.  317,  321,  and  323). 

Various  attempts  have  been  made  to  apply  the  principle 
of  axis-traction  in  other  ways.  (1)  It  is  maintained  that 
axis-traction  can  be  made  with  sufficient  accuracy  with  the 
ordinary  long  forceps  by  the  manoeuvre  of  Pajot  (Fig.  325). 
The  right  hand  grasps  the  handles,  making  forward  traction 
upon  them  ;   the  left  grasps  the  shanks  above  the  lock  and 

*  The  use  of  rubber  gloves  for  the  forceps  operation  is  optional. 


FORCEPS 


697 


makes  backward  traction  upon  that  part  of  the  instrument, 
forming  a  fulcrum  between  the  two  hands,  upon  which  the 
blades  will  swing  somewhat  backwards  when  traction  is 
being  applied.  It  is  clear  that  it  will  be  impossible  to  obtain 
even  approximate  accuracy  of  direction  in  this  manner. 
(2)  The  second  method  is  that  of  Neville  (Fig.  326).  Neville's 
forceps  differs  from  Milne  Murray's  in  having  but  a  single 
traction  rod,  which  is  attached  to  the  forceps  just  below  the 
lock  by  a  butterfly  joint.  The  traction  bar  is  differently 
jointed,  but,  like  Milne  Murray's,  will  move  in  all  directions. 
The  advantage  possessed  by  this  instrument  is  that  it  is 


Fig.  326. — Neville's  Axis-traction  Forceps. 

easier  to  apply  than  Milne  Murray's,  but  the  direction  of 
traction  is  probably  not  so  accurate. 

It  must  be  recollected  that  the  axis-traction  forceps  is 
designed  to  work  in  a  pelvis  of  normal  shape  :  when  the 
pelvis  is  contracted  so  as  to  distort  its  axis  many  of  the 
advantages  which  the  instrument  possesses  are  lost.  This 
objection,  of  course,  does  not  apply  to  its  use  in  the  generally 
contracted  pelvis. 

Modes  of  Action  of  Obstetric  Forceps. — The  action  of 
the  obstetric  forceps  is  essentially  that  of  making  traction  ; 
the  blades  also  compress  the  head,  but  the  amount  of  com- 
pression  should  be  only  so  much  as  is  required  to  ensure  a 
firm  grasp.  When  properly  applied  the  possible  degree  of 
compression  is  small,  and  is  strictly  limited  by  the  cephalic 


698  OBSTETRIC   OPERATIONS 

curve  of  the  instrument.  If  the  head  is  gripped  transversely, 
the  bi-parietal  diameter  cannot  be  reduced  below  3f  inches. 
It  is  probable  that  prolonged  compression  of  the  head  even 
to  this  extent  may  cause  a  certain  amount  of  injury  to  the 
brain,  for  in  such  cases  the  child  is  often  born  in  a  condition 
of  white  asphyxia.  But  injury  to  the  cranial  bones  cannot 
be  produced  by  this  grip  if  the  pelvis  is  normal.  As  we  shall 
see,  the  usual  grip  obtained  is  transverse,  or  slightly  oblique 
from  before  backwards. 

It  is  when  the  instrument  is  so  applied  as  to  take  an 
antero-posterior  grip  of  the  head  that  there  is  the  greatest 
risk  of  injury.  Reduction  of  size  in  this  plane  is  followed  by 
a  compensatory  increase  in  the  vertical  diameter — i.e.,  the 
distance  between  the  vertex  and  the  base  is  increased.  The 
transverse  (bi-parietal)  diameter  is  not  much  affected. 

In  occipito-posterior  positions  the  forceps  is  sometimes 
used  forcibly  to  rotate  the  head  so  as  to  bring  the  occiput 
forwards.  This  cannot  be  done,  however,  without  risk  of 
injury  to  the  soft  parts. 

A  lateral  lever  action  may  be  exerted  during  traction  by 
carrying  the  handles  gently  from  side  to  side  ;  this  sometimes 
aids  extraction  in  a  difficult  case. 

It  is  also  clear  that,  when  the  head  is  in  the  grasp  of  the 
forceps,  the  lower  parts  of  the  blades  will  exercise  a  dilating 
action  upon  the  vulva  immediately  in  advance  of  the  head 
(Fig.  333).  And  lastly,  the  mere  introduction  of  the  blades 
often  exerts  a  powerful  excitant  action  upon  the  uterine 
contractions. 

The  variety  of  obstetric  forceps  which  will  be  found  most 
generally  useful  is  the  axis-traction  forceps  ;  and  Milne 
Murray's  pattern  is  to  be  preferred  on  account  of  its  greater 
accuracy.  To  operators  who  have  become  accustomed  to 
the  ordinary  long  forceps,  the  axis-traction  forceps  appears 
clumsy  and  its  application  difficult  ;  but  students  can  learn 
to  apply  it  quite  as  easily  as  the  long  forceps.  It  is  a  great 
advantage  to  carry  one  kind  of  forceps  only,  and  this  is  the 
only  kind  which  is  sufficient  for  all  the  requirements,  whether 
of  an  easy  or  a  difficult  case.  It  is  advantageous  also  to  use 
the  same  form  of  instrument  in  all  forceps  operations,  so  as 
to  become  thoroughly  familiar  with  its  use  ;  and  while  it 
may  be  admitted  that  a  low  forceps  operation  can  be  easily 


FORCEPS  699 

performed  with  the  ordinary  long  instrument,  this  certainly 
is  not  the  case  with  a  high  operation  ;  here  the  axis-traction 
instrument  is  far  more  effective.  The  same  must  be  said  of 
pelvic  contraction  and  all  other  conditions  in  which  a  con- 
siderable amount  of  force  is  required  in  traction  ;  the  axis- 
traction  pattern  is  far  more  effective.  Since  all  the  force 
applied  through  the  instrument  is  effective,  and  none  is  lost, 
obviously  the  amount  of  force  required  is  reduced  to  the 
minimum.  When  the  head  is  low  in  the  pelvic  cavity  the 
blades  can  be  used  without  the  traction  rods,  like  an  ordinary 
pair  of  long  forceps. 

It  must  also  be  borne  in  mind  that  this  forceps  does  not 
interfere  with  the  normal  movement  of  rotation  made  by  the 
head  in  passing  through  the  pelvis,  for  the  ball-and-socket 
joint  on  the  traction  handle  allows  the  instrument  and  the 
head  to  rotate  together.  With  the  ordinary  forceps,  owing 
to  the  firm  grip  of  the  handles  which  is  required,  spontaneous 
rotation  cannot  occur,  although  of  course  forcible  rotation 
can  be  performed  by  the  operator. 

It  has  been  urged  that  excessive  and  continuous  compres- 
sion of  the  head  is  caused  by  the  screwing  together  of  the 
handles  of  the  axis-traction  forceps  ;  this  is  not  the  case, 
for,  as  we  shall  see,  continuous  compression  implies  improper 
use  of  the  instrument  ;  the  degree  of  compression  required  is 
only  that  necessary  to  ensure  a  firm  grip  of  the  head,  and  this 
can  be  regulated  with  far  more  accuracy  by  the  screw  than 
when  the  handles  are  firmly  gripped  in  the  act  of  making 
traction.  The  only  valid  objection  to  the  instrument  is 
its  greater  complexity,  and  the  corresponding  greater  diffi- 
culty in  manipulating  it  ;  this  can  be  readily  overcome  by 
practice. 

Indications  for  the  Use  of  Forceps. — The  obstetric  forceps 
is  an  instrument  designed  for  application  to  the  head  in  pre- 
sentations of  the  vertex,  brow,  or  face,  and  to  the  after- 
coming  head  in  breech  labours.  It  is  also  by  some  authorities 
applied  directly  to  the  breech  in  breech  presentations,  but 
the  instrument  is  not  adapted  for  this  purpose ;  other 
methods  of  delivering  a  difficult  breech  presentation  can 
always  be  employed  with  success. 

When  the  head  has  passed  through  the  brim,  and  lies 
with  its  greatest  circumference  in  the  pelvic   cavity,   the 


700  OBSTETRIC   OPERATIONS 

operation  is  simple  and  easy  ;  the  lower  the  head  has 
descended  before  the  forceps  is  applied,  the  easier  will  be  the 
extraction.  This  is  often  spoken  of  as  the  low  forceps  opera- 
tion. When  the  head  lies  entirely  above  the  pelvic  brim, 
freely  movable,  unengaged  and  unmoulded,  the  operation  is 
very  difficult  to  perform  and  involves  considerable  danger  to 
the  child.  If  the  pelvis  is  contracted  or  the  head  abnormally 
large  these  difficulties  and  risks  are  considerably  increased. 
This  operation,  which  is  often  spoken  of  as  the  high  forceps 
operation,  is  accordingly  not  to  be  recommended  unless  other 
methods  of  delivery  per  vias  naturales,  such  as  internal 
version,  are  impracticable.  While  the  operation  cannot  be 
actually  condemned,  it  should  never  be  undertaken  lightly, 
or  without  first  giving  due  consideration  to  other  possible 
methods  of  delivery. 

It  will  be  clear  that  cases  may  be  met  with  intermediate 
between  these  two  classes — i.e.,  cases  in  which,  although  the 
head  is  engaged  in  the  brim  and  partly  moulded,  the  greatest 
circumference  has  yet  failed  to  pass  through  the  pelvic  uilet. 
In  such  cases  resort  to  forceps  should  be  delayed  as  long  as 
may  be  possible,  due  watch  being  kept  upon  the  condition 
of  the  foetal  heart,  and  the  general  condition  of  the  mother. 
If  the  pelvis  is  of  normal  size  the  operation  may  be  under- 
taken earlier  and  with  better  prospects  of  success  than  when 
the  pelvis  is  contracted.  The  importance  of  allowing  full 
time  for  moulding,  in  the  latter  condition,  has  been  already 
insisted  upon. 

The  actual  indications  for  the  use  of  forceps  in  head  pre- 
sentations may  be  arranged  into  three  groups  : 

(1)  Abnormal  prolongation  of  the  second  stage. 

(2)  Maternal  complications. 

(3)  Foetal  dangers,  indicated  by  signs  of  distress  or  pro- 

lapse of  the  cord. 

In  breech  presentations,  if  the  after-coming  head  cannot 
be  promptly  delivered  by  the  digital  methods  described  on 
p.  369,  the  forceps  should  be  at  once  applied. 

(1)  Prolongation  of  the  second  stage. — Forceps  should  not 
be  applied  merely  to  save  the  time  of  the  medical  attendant, 
or  to  shorten  the  duration  of  the  second  stage  when  labour  is 
proceeding  naturally.  The  length  of  the  second  stage  is 
variable,  and  for  practical  purposes  the  strength  of  the  pains 


FORCEPS  701 

must  be  taken  into  consideration,  as  well  as  the  actual  time 
which  has  elapsed.  When  the  pains  are  feeble  and  irregular, 
much  more  time  must  be  allowed  than  when  they  are  strong 
and  regular.  When  the  head  is  detained  in  the  upper  part 
of  the  pelvis  the  use  of  forceps  should  be  withheld  as  long  as 
possible.  When  it  has  reached  the  pelvic  floor  and  presents 
at  the  vulva  there  is  not  the  same  reason  for  delay. 

These  points  being  borne  in  mind,  the  following  con- 
ditions may  be  enumerated  as  causes  of  abnormal  prolonga- 
tion of  the  second  stage  : 

{a)  Uterine  inertia — primary  or  secondary, 
(6)  Occipito-posterior  positions, 

(c)  Rigidity  of  the  perineum, 

(d)  Pelvic  contraction. 

(e)  Abnormally  large  size  of  the  head. 
(/)  Abnormal  uterine  obliquity. 

(g)  Mento-posterior  positions  of  the  face. 

In  every  case  an  attempt  should  be  made,  before  applying 
forceps,  to  arrive  at  a  conclusion  as  to  the  cause  of  the  delay. 
It  will  be  found  that  the  three  first-named  conditions  account 
for  something  like  90  per  cent,  of  the  cases  in  which  the 
forceps  is  used.  When  the  head  is  delayed  on  the  pelvic 
floor  the  usual  cause  is  to  be  found  in  ineffective  contractions, 
or  an  unyielding  perineum  ;  in  rare  instances  contraction 
of  the  pelvic  outlet  may  be  present  as  in  a  funnel  pelvis. 
When  the  head  is  detained  in  the  upper  part  of  the  pelvic 
cavity,  and  the  uterus  is  contracting  well,  the  commonest 
causes  are  a  posterior  position,  or  some  disproportion 
between  the  size  of  the  head  and  that  of  the  pelvis.  In  the 
latter  an  abnormally  large  caput  will  form,  and  the  head  will 
become  fixed  ;  in  the  former  the  caput  is  not  abnormally 
large  and  the  head  usually  remains  movable.  Therefore, 
when  the  delayed  head  shows  a  large  caput,  attention  must 
always  be  directed  to  the  size  of  the  pelvis. 

(2)  Maternal  complications. — In  such  conditions  as  heart 
disease  it  is  obvious  that  prolongation  of  the  muscular  strain 
which  accompanies  the  second  stage  must  be  detrimental  to 
the  mother,  and  accordingly  forceps  should  be  employed 
early  in  this  stage.  In  eclampsia  all  obstetricians  agree  that 
-  as  soon  as  the  cervix  is  sufficiently  dilated  extraction  with 


702  OBSTETRIC   OPERATIONS 

forceps  is  indicated  ;  as  in  the  majority  of  cases  labour  is 
j)reniatiire  and  the  fcBtus  small,  extraction  is  not  often 
difficult,  even  in  a  primipara.  Sometimes  in  cases  of  pre- 
mature rupture  of  the  membranes  signs  of  obstetric  exhaus- 
tion may  appear  before  dilatation  has  been  completed,  and 
to  these  may  be  added  signs  of  foetal  distress.  Under  such 
circumstances  prompt  delivery  by  forceps  must  be  practised, 
the  dilatation  having  been  previously  comj)leted  by  the 
digital  method,  or  with  the  additional  aid  of  incisions  in 
the  cervix. 

(3)  Foetal  complications. — The  early  use  of  forceps  may 
be  indicated  by  signs  that  the  foetus  is  suffering  from  the 
effects  of  labour,  such  as  passage  of  meconium,  or  slowtug  of 
the  rate  of  the  heart  sounds.  This  is  especially  likely  to 
occur  with  a  premature  foetus  or  with  j)remature  rupture  of 
the  membranes.  Prolapse  of  the  cord  may  also  call  for  the 
early  use  of  forceps.  When  the  foetus  is  dead,  forceps 
dehvery  is  suitable  as  long  as  the  jjelvis  is  of  normal  size  and 
the  head  is  not  abnormally  large.  But  in  such  cases,  should 
extraction  prove  to  be  difficult,  the  forceps  should  be  at  once 
abandoned  in  favour  of  craniotomy. 

Forceps  in  Pelvic  Contraction. — It  has  been  already 
mentioned  in  connection  with  the  management  of  labour 
in  pelvic  contraction  (p.  416)  that  unless  the  conjugate 
measures  at  least  3^  inches,  a  full-time  child  of  average  size 
cannot  be  extracted  by  forceps  without  great  risk  of  seriously 
injuring  it.  Consequently  it  is  better  not  to  undertake  for- 
ceps delivery  in  a  pelvis  smaller  than  3^  inches.  If  a  case  is 
first  seen  at  an  advanced  period  of  labour,  when  the  head  is 
firmly  engaged  m  the  brim,  accurate  measurement  of  the 
pelvis  is  impossible.  We  must  then  be  guided  by  the  amount 
of  compression  of  the  head  which  has  taken  place,  as  indicated 
by  overlapping  of  bones  and  by  the  size  of  the  caput.  It  has 
been  already  explained  that  an  uimioulded  head  is  much 
more  difficult  to  deUver  than  one  hi  which  moulding  has 
definitely  occurred  ;  but  if  the  greater  part  of  the  head, 
though  moulded,  remains  above  the  pelvic  brim,  the  prospects 
of  delivery  by  forceps  are  unfavourable. 

In  all  cases  of  pelvic  contraction  attempts  to  dehver  with 
forceps  must  be  made  carefully,  and  should  not  be  persisted 
in  if  no  progress  is  being  made  after  two  or  three  steady  pulls. 


FORCEPS 


703 


The  shape  of  the  pelvis  is  not  of  much  importance  from 
the  point  of  view  of  the  forceps  operation  ;  in  both  fiat  and 
generally  contracted  pelves  it  may  be  used  with  equal  success 
in  suitable  cases.  After  failure  to  deliver  with  forceps  it  is, 
as  a  rule,  unwise  to  attempt  version  ;  if  the  head  is  firmly 
engaged  in  the  brim  and  there  is  little  liquor  amnii  present, 
version  should  never  be  performed,  owing  to  the  risk  of 
rupturing  the  uterus  ;   if,  however,  these  conditions  are  not 


■  '■•"t.i-^0/^^^'^ 


Fig.  327. 


-Ap23lication  of  Axis-traction  Forceps.     Introducing 
the  left  blade. 


present,  version  may  be  performed  if  the  pelvis  is  flat,  but 
never  if  it  is  generally  contracted.  In  all  varieties  of  con- 
tracted pelvis,  axis-traction  forceps  are  much  more  successful 
than  the  ordinary  long  forceps. 

Application  and  Use  of  Forceps. — Preliminaries. — Care- 
ful antiseptic  preparation  of  the  hands  of  the  operator  and 
the  vulva  of  the  patient  is  of  course  necessary.  In  some 
schools  of  midwifery  the  use  of  sterilised  rubber  gloves  by 
the  operator  is  advised  in  all  cases.  In  the  opinion  of  the 
author  this  precaution  is  not  necessary  in  the  low  operation. 


704  OBSTETRIC   OPERATIONS 

but  should  be  used  in  the  high  operation,  as  it  is  never 
desirable  to  introduce  the  entire  uncovered  hand  into  the 
vagina.  Shaving  and  disinfecting  the  vulva  is  a  much  more 
valuable  preventive  of  infection  than  the  use  of  gloves  by 
the  operator,  and  in  the  author's  opinion,  it  should  be  prac- 
tised whenever  the  patient  is  anaesthetised  for  any  obstetric 
operation.  If  sterilised  gloves  become  soiled  in  passing 
through  the  vulva  the  chief  advantage  of  using  them  is 


ElG.  328. — Application  of  Axis-traction  Forceps.  The  left  blade  is  in 
position,  the  handle  only  being  seen ;  the  right  blade  is  being 
introduced. 


lost.  The  previously  boiled  forceps  should  be  immersed  in 
a  large  ewer  of  lysol  solution  (5j.  to  Oj.)  or  carbolic  (1  in  40) 
until  required  for  application.  The  bladder  must  always  be 
emptied  by  catheter,  and  an  anaesthetic  is  desirable  in  all 
cases.  The  left  lateral  posture,  the  patient  lying  across  the 
bed,  is  usually  employed  in  this  country,  but  the  dorsal 
posture,  with  the  legs  flexed  and  the  buttocks  drawn  to  the 
edge  of  the  bed  (Fig.  337),  is  of  great  assistance  in  cases  of 
difficulty,  and  the  operator  should  become  familiar  with  it  ; 
the  former  has  the  advantage  of  requiring  fewer  assistants. 


FORCEPS  705 

When  the  lateral  posture  is  used  the  buttocks  are  drawn 
over  the  edge  of  the  bed,  and  the  right  leg  must  be  supported 
throughout  the  operation  by  an  assistant  in  the  position 
shown  in  Fig.  327.  A  detailed  examination  of  the  presenting 
head  should  first  be  made,  and  for  this  purpose  it  is  necessary 
to  pass  the  '  half  hand  '  into  the  vagina.  This  will  enable 
the  operator  in  cases  of  difficulty  to  locate  the  ears,  which 
are  useful  in  the  diagnosis  of  position  when  the  sutures  and 
fontanelles  are  obscured  by  a  large  caput.  The  curve  of  the 
helix  always  corresponds  with  the  occipital  end  of  the 
head.  Posterior  positions  should,  if  possible,  be  corrected 
by  manual  rotation.  If  the  cervix  is  incompletely  dilated, 
the  requisite  degree  of  dilatation  should  be  secured  by  the 
digital  method,  aided  in  some  cases  by  lateral  incisions.  If 
the  membranes  remain  unbroken  they  should  of  course  be 
ruptured  artificially. 

Application  of  the  Axis-traction  Forceps. — {a)  When  the 
head  is  in  the  lower  part  of  the  pelvic  cavity. — In  a  simple  case 
the  blades  are  applied  in  the  transverse  diameter  of  the 
pelvic  cavity.  As  a  rule  the  movement  of  internal  rotation 
is  incomplete,  and  consequently  the  blades  grip  the  head 
in  its  oblique  diameter — i.e.,  intermediate  between  the 
transverse  and  the  antero-posterior.  If  internal  rotation 
is  complete  the  head  will  be  gripped  in  its  biparietal 
diameter. 

The  left  half  is  usually  applied  first  ;  this  will  be  the  lower 
half  in  the  left  lateral  posture.  The  handle  is  held  lightly  in 
the  right  hand,  the  traction  rod  being  kept  in  close  contact 
with  the  shank.  The  fingers  of  the  left  hand  are  passed  into 
the  vulva  and  carried  up  into  contact  with  the  cervix  on  the 
left  side  of  the  head.  The  blade  is  then  passed  along  the 
palmar  surface  of  the  fingers  in  the  antero-posterior  diameter 
of  the  vulva,  and  directed  at  first  backwards  towards  the 
sacral  hollow,  the  instrument  being  held  in  a  nearly  vertical 
position  as  shown  in  Fig.  327.  The  handle  is  then  carried 
backwards  in  a  wide  sweep,  and  the  blade  at  the  same  time 
directed  by  the  internal  fingers  to  the  left  (of  the  mother) 
until  it  lies  in  the  transverse  pelvic  diameter  ;  the  blade  must 
be  kept  in  contact  with  the  scalp,  the  lip  of  the  external  os 
being  protected  by  the  fingers.  This  movement  sweeps  the 
blade  round  the  left  (maternal)  side  of  the  head.  Without 
E.M.  45 


■ijtj 


OBSTETRIC   OPERATIONS 


exerting  am'  force,  the  blade  will  be  found  to  pass  deeply  the 
pelvis  until  the  shank  comes  to  lie  upon  the  perineum 
(Fig.  327).  The  traction  rod  now  hes  behind  the  applied 
blade.  The  left  blade  may  be  held  in  position  by  an  assistant 
as  shown  in  Fig.  329  ;  unless  held  in  this  way  while  the  other 
blade  is  being  introduced  it  will  not  remain  in  the  position  in 
which  it  has  been  placed.     The  right  half  of  the  forceps  is 


^tuMmt^iii^^t*^ — 


<k.pm 


Fig.  3-9. — Ap]»]icatioii  of  Axis- traction  Forceps.     Further  stage  in 
introduction  of  the  ri^ht  blade. 


next  taken  in  the  right  hand,  the  left  hand  is  pronated,  and 
the  fingers  used  as  before  to  guide  it  into  the  vulva.  The 
blade  is  first  directed  towards  the  sacral  hoUow,  and  then, 
the  handle  being  held  j)araUel  to  the  left  thigh,  the  blade  is 
directed  by  the  fingers  round  the  right  side  of  the  pelvis  into 
the  transverse  diameter,  the  same  precautious  being  taken 
as  in  introducmg  the  left  half.  It  is  necessary  to  depress 
the  handle  of  the  right  half  in  order  to  carrs^  the  blade 
upwards  to  the  right  side  of  the  pelvis  (Fig.  329).     The  move- 


FORCEPS 


707 


ment  is  completed  by  carrying  the  handle  backwards,  as  the 
blade  passes  deeply  into  the  pelvis.  Both  traction  rods 
should  now  lie  behind  the  shanks,  and  the  instrument  is 
locked  by  taking  a  handle  in  each  hand  and  carefully  adjust- 
ing the  slots  (Fig.  330).  It  is  convenient  to  have  the  trac- 
tion rods  held  back  by  the  fingers  of  an  assistant  when 
locking  the  forceps  ;  but  this  is  not  required  after  a  little 
practice.  If  the  instrument  has  been  accurately  applied  the 
shanks  will  lie  in  such  a  position  that  locking  is  easy  ;  some- 
times however  the  blades  lie  so  that  they  cannot  be  locked 


Fio.  .'^30. 


-Application  of  Axis-traction  Forceps.     Locking  the  blades  ; 
ihn  traction  rods  are  held  aside  by  an  assistant. 


without  forcibly  rotatmg  one  or  both  of  them,  in  order  to 
adjust  the  slots  to  one  another.  If  the  blades  have  been 
carefully  applied  in  the  transverse  diameter  of  the  pelvis, 
difficulty  in  locking  signifies  that  rotation  of  the  head  has 
not  occurred,  and  the  blades  should  be  removed  and  re- 
applied in  an  oblique  diameter  of  the  pelvis  {vide  infra). 
Serious  injury  to  the  head  may  result  from  forcibly  lock- 
ing badly  adjusted  blades.  After  locking,  the  application 
handles  are  screwed  lightly  together  with  the  fixation  screw. 
They  lie  against  the  perineum,  and  it  will  be  noticed  that  they 
are  directed  downwards  in  the  axis  of  the  pelvic  cavity 

45—2 


708 


OBSTETRIC   OPERATIONS 


(Fig.  331).  Next  the  traction  rods  are  connected,  and  the 
traction  handle  apphed.  A  careful  examination  should  be 
made  before  traction  is  begun,  to  make  sure  that  nothing 
but  the  head  has  been  included  ui  the  grip  of  the  instrument. 
Difficulty  in  the  application  and  adjustment  of  the  blades, 
if  not  due  to  inexperience,  usually  results  from  a  faulty 
position  of  the  head.  In  occipito-posterior  positions,  when 
rotation  has  not  occurred  either  forwards  or  backwards, 


Fig.  33] . — Showing  the  Position  of  the  Traction  Eods  and  Handles 
after  the  instriiment  has  been  applied. 


there  is  often  great  difficult}^  in  obtaining  a  satisfactory  grip 
of  the  head  when  the  blades  have  been  applied,  as  described, 
in  the  transverse  diameter  of  the  pelvis.  It  has  already  been 
explained  that  such  cases  should,  if  possible,  be  treated  by 
manual  rotation  before  forceps  is  appUed  (see  p.  340).  When 
the  head  lies  in  an  oblique  diameter  with  the  occiput  for- 
wards the  difficulty  can  be  overcome  by  applying  the  blades 
not  in  the  transverse  diameter,  but  in  one  of  the  oblique 
diameters  of  the  pelvis.  Thus  in  a  first  position  the  left 
blade  would  be  directed  towards  the  left  sacro-iliac  syn- 


FORCEPS 


709 


chondrosis,  the  right  towards  the  right  pectineal  eminence, 
so  that  the  instrument  would  lie  in  the  left  oblique  diameter, 
and  would  thus  obtain  a  grip  of  the  head  in  its  biparietal 
diameter.  In  a  second  position  the  blades  would  lie  in  the 
right  obhque  diameter,  the  left  blade  being  carried  a  little 
in  front  of  the  transverse,  the  right  a  httle  behind  it.  While 
traction  is  being  made  rotation  will  occur,  as  the  head 
comes  down,  either  in  a  forward  or  backward  direction, 
according  to  the  conditions  previously,  discussed  (p.  299). 


Fig.  332. — T)elivery  by  Axis-traction  forceps.     Tiaction  in  the 
direction  of  the  axis  of  the  pelvic  cavity. 

Before)  delivering  the  head  the  blades  should  then  be  taken 
off  and  reapplied  in  the  transverse  diameter. 

Extraction  of  the  Head. — Three  points  must  be  continu- 
ally borne  in  mind  in  extracting  the  head  with  the  axis- 
traction  forceps  :  (1)  to  keep  the  traction  rods  always  in 
contact  with  the  shanks  ;  (2)  to  pull  only  during  uterme 
contractions  and  to  pause  during  the  intervals  ;  (3)  to  ease 
the  fixation  screw  whenever  traction  is  not  being  made. 
In  the  low  operation  the  direction  of  traction  will  be  at 
first  downwards,  but  as  the  head  descends  the  application 
handles  will  of  themselves  move  forwards,  and  the  traction 
rods  must  be  made  to  follow  them  (Figs.  332  and  333)  ; 
if  this  point  is  carefully  attended  to  traction  will  always  be 


710 


OBSTETRIC   OPERATIONS 


made  exactly  in  the  pelvic  axis.  Little  or  no  time  will  be 
lost  in  pausing  during  the  periods  of  relaxation  of  the  uterus, 
unless  the  patient  is  deeply  anaesthetised,  for  the  presence 
of  the  instrument  in  the  genital  canal  powerfully  excites 
uterine  contractions.  The  object  of  easing  the  screw  of  the 
apphcation  handles  is  of  course  to  avoid  the  risk  of  prolonged 
and  contmuous  compression  of  the  head.  When  the  head 
and  the  pelvis  are  of  normal  size,  the  amount  of  force  required 
with  this  instrument  is  small,  and  delivery  can  often  be 
effected  by  makhig  traction  with  two  fingers  only.     If  during 


Fig.  333. — Delivery  by  Axis-traction  Forceps.     Traction  in  tlie  dii-ection 
of  the  axis  of  the  pelvic  outlet. 


traction  the  instrument  should  be  felt  to  slip,  it  must  be 
taken  off  and  re-apphed.  When  marked  rotation  of  the 
head  occurs  during  its  descent,  so  as  to  bring  the  blades 
nearly  or  quite  into  the  antero-posterior  diameter,  the  instru- 
ment should  be  removed  and  re-apphed,  or  serious  lacera- 
tion of  the  vulva  may  be  caused  by  the  edges  of  the  blades. 
When  using  the  lateral  position  in  the  fuial  stage  of  extrac- 
tion, the  luie  of  traction  required  is  across  the  body  of  the 
patient,  and  the  handles  will  come  into  a  line  almost  parallel 
with  the  anterior  surface  of  the  pubes  (Fig.  333).  The  instru- 
ment may  now  be  gripped  by  the  shanks  mth  the  right  hand, 
until  the  head  is  fixed  in  the  outlet,  when  the  forceps  may 


FORCEPS 


711 


be  removed  and  the  head  dehvered  by  expression.  In 
removing  the  instrument  the  traction  handle  is  first  taken  off, 
then  the  fixation  screw  loosened  and  the  traction  rods 
disconnected  from  one  another  ;  the  blades  can  then  be 
separately  withdrawn. 

(b)  When  the  head  is  in  the  upper  part  of  the  pelvic  cavity. — 
In  these  cases  a  careful  estimate  must  be  made  of  the  size  of 
the  pelvis,  and  the  relative  size  of  the  foetal  head.  In  the 
absence  of   uterine   inertia,  some  degree  of  obstruction  is 


Fig.  334.— Wiilcher's  Position.     (Edgar.) 

the  commonest  cause  of  arrest  of  the  head  in  this  part 
of  the  pelvis.  The  presence  of  an  unusually  large  caput, 
and  of  extreme  cranial  moulding,  would  also  suggest  that 
some  degree  of  obstruction  is  present.  Before  applying 
forceps  it  is  therefore  desirable  to  endeavour  to  estimate  the 
amount  of  pelvic  space  which  is  available.  It  is  very  diffi- 
cult to  measure  the  diagonal  conjugate  during  labour  when 
the  head  is  firmly  engaged  in,  or  has  passed,  the  brim.  A 
careful  bi-manual  examination  of  the  head,  after  the  method 
of  Miiller  (p.  421)  should  be  made,  so  as  to  observe  the  size 
of  that  portion  which  still  lies  above  the  brim.  If  the  greatest 


712 


OBSTETRIC   OPERATIONS 


cranial  circumference  has  not  passed  through,  great  diffi- 
culty in  delivery  with  forceps  may  be  experienced.  If  the 
pelvis  is  normal  and  the  head  of  not  more  than  average 
size,  arrest  m  the  upper  part  of  the  pelvis  is  usually  the  result 
of  insufficiency  of  the  pauis.  It  is  sometimes  difficult  in  high 
cases  to  obtain  a  firm  grip  of  the  head,  the  forceps  shpping 
as  soon  as  traction  is  begun.     This  accident  will  usually  be 


Fig.  3.'35. — The  Axis-traction   Forceps   in    Walcher's    Position,  showing 
the  direction  in  which  traction  is  made. 


found  to  be  due  to  non-rotation  of  an  occipito-posterior 
position. 

(c)  When  the  pelvis  is  contracted. — If  the  pelvis  is  flat  the 
head  nearly  always  engages  in  the  transverse  diameter  ; 
consequently  in  appljdng  the  forceps  in  that  diameter,  an 
occipito-frontal  grip  of  the  head  will  be  obtained.  This 
grip  is  certainly  more  likely  to  cause  cranial  injuries,  but 
does  not  increase  the  difficulty  of  delivery,  smce  the  com- 


FORCEPS 


713 


pensatory  increase  occurs  not  in  the  bi-parietal  diameter, 
but  in  a  vertical  diameter  of  the  head.  It  is  of  no  use  to 
attempt  to  grip  the  head  in  any  other  diameter  in  such  cases. 

Having  apphed  the  blades,  one  or  two  tentative  pulls 
should  be  made  to  make  sure  that  the  grip  of  the  instrument 
is  secure.  The  patient  should  then  be  placed  in  Walcher's 
position  for  the  extraction  of  the  head  (Fig.  335).  In  this 
position  the  patient  is  placed  upon  her  back^  with  the  but- 
tocks over  the  edge  of  the 
couch  and  slightly  elevated 
on  firm  pillows.  The  couch 
or  bed  must  be  high  enough 
to  allow  the  lower  limbs  to 
hang  over  the  end  without 
touching  the  floor.  The 
effect  of  the  hanging  posi- 
tion of  the  legs  is  to  alter 
the  angle  of  the  plane  of 
the  brim  so  as  to  reduce  its 
inclination  to  the  horizon- 
tal, and  also  slightly  to 
lengthen  the  conjugate  dia- 
meter of  the  brim.  This 
position  will  therefore 
allow  of  the  easier  delivery 
through  the  brim  of  a 
tightly  fitting  head.  In 
pulling  the  head  through 
the  brim  the  line  in  which 
it  must  move  will  be 
nearly    vertical,     for    the 

axis  of  the  brim  in  its  altered  inclination  is  more  nearly 
vertical  than  in  the  usual  position.  The  operator  sits  upon 
the  floor  between  the  patient's  thighs  (Fig.  335).  When  the 
head  has  passed  through  the  brim,  the  legs  should  be  flexed 
and  supported  by  assistants,  while  the  operator  changes  the 
line  of  traction,  directing  it  rather  sharply  forwards  as  the 
head  reaches  the  outlet.  If  internal  rotation  now  occurs, 
the  forceps  should  be  taken  off  and  re-applied  to  avoid 
delivering  the  head  in  an  oblique  diameter. 

In  the  generally  contracted  ^pelvis  Walcher's  position  is 


Fig 


336. — Showing  the  favourable 
Grip  of  the  Forceps  in  an  Occipito- 
anterior Position. 


714  OBSTETRIC   OPERATIONS 

not  of  the  same  advantage,  since  the  whole  pelvis  is  small, 
whereas  in  the  flat  variety  the  difficulty  is  solely  or  mainly 
at  the  brim.  The  difficulty  of  forceps  delivery  is  accordingly 
greater  in  a  generally  contracted  pelvis,  and  there  is  more 
risk  of  injury  to  the  child. 

In  the  funnel  ^pelvis  great  difficulty  may  be  met  with  in 
delivering  the  head  through  the  outlet.  Whitridge  Williams 
has  shown  that  Sims'  position  and  the  elevated  lithotomy 
position  are  both  of  great  service  here  as  they  produce  an 
appreciable  enlargement  of  the  antero-posterior  diameter 
of  the  outlet.  In  the  elevated  lithotomy  position  the 
patient  is  supported  with  a  Clover's  crutch,  and  the  buttocks 
are  further  raised  above  the  level  of  the  table  on  a  firm 
pillow  before  the  forceps  is  applied.  The  Sims'  position  is 
described  on  p.  322. 

Application  and  Use  of  Ordinary  Long  Forceps. — The 
application  of  the  blades  is  carried  out  ui  precisely  the  same 
manner  as  the  axis-traction  forceps  up  to  the  locking  of  the 
handles  ;  traction  can  then  be  at  once  commenced.  The 
same  precautions  in  delivering  should  be  observed  ;  the  firm 
grip  of  the  handles,  which  is  necessarily  used  when  making 
traction,  probably  exerts  more  injurious  pressure  upon  the 
head  than  does  the  fixation  screw  of  the  axis-traction 
instrument ;  during  the  intervals  the  handles  should  accord- 
ingly be  slightly  separated  without  actually  unlocking  them, 
so  as  to  diminish  the  pressure  upon  the  head.  Great  care 
must  be  exercised  throughout  in  directing  traction  as  far 
as  possible  in  the  pelvic  axis  ;  the  difficulties  of  effectmg  this 
have  been  already  referred  to. 

The  blades  of  axis-traction  forceps,  without  the  traction 
rods,  may  be  used  as  a  substitute  for  the  ordmary  long 
forceps.  When. the  indication  for  speed  is  urgent,  as  in 
forceps  extraction  of  the  after-coming  head,  this  instrument 
is  preferable,  as  it  can  be  applied  more  rapidly. 

Application  of  Forceps  in  the  Dorsal  Position.- — In  cases  of 
difficulty,  such  as  an  unreduced  occipito-posterior  position, 
or  a  contracted  pelvis,  the  dorsal  position  will  often  be  found 
to  allow  of  easier  delivery  with  forceps  than  the  lateral 
position.  It  is  therefore  desirable  to  become  practised  in 
the  use  of  the  instrument  in  this  position.  The  operator 
stands  between  the  flexed  and  abducted  thighs,  which  are 


FORCEPS 


715 


held  by  assistants.     The  left  half  should  be  passed  first  as 
shown  in  Fig.  337  ;    the  blade  is  directed  first  of    all  back- 


FlG.  337.— Application  of  Ordinary  Long  Forceps  in  the  Dorsal  Position. 

Introducing  the  left  blade. 

The  instrument  used  in  Figs.  337  and  388  is  an  axis-traction  forceps  without  the 
traction  rods. 

wards  into  the  sacral  hollow,  and  then  into  the  transverse 
diameter,  the  handle  being  swept  over  to  the  right  (of  the 


716 


OBSTETRIC   OPERATIONS 


mother)  and  then  backwards  on  to  the  perineum.  In 
introducing  the  right  half,  the  blade  is  passed  over  the  left 
(Fig.  338),  and  then  directed  into  the  transverse  diameter, 


Fig.  338. — Application  of  Ordinary  Long  Forceps  in  the  Dorsal  Position. 
Introducing-  the  right,  blade. 


the  handle  being  swept  over  to  the  left  (of  the  mother)  and 
then  backwards  to  meet  the  handle  of  the  left  half  which 
has  been  already  introduced.  In  the  figures  the  instrument 
'used  is  the  axis-traction  forceps  without  the  traction  rods. 


FORCEPS 


717 


The  presence  of  the  latter  undoubtedly  renders  the  applica- 
tion of  forceps  in  this  position  somewhat  difficult,  but  the 
difficulty  can  be  readily  overcome  by  keeping  the  traction 
rods  always  below  {i.e.,  behind)  the  handles.  In  extracting 
the  head  through  the  outlet  in  this  position  it  must  be  remem- 
bered that  the  direction  of  traction  will  be  upwards  and 
forwards,  i.e.,  towards  the  operator. 

Forceps  in  Face  Cases. — In  applying  the  instrument  in 


Fig, 


339. — The  Grip  of  the  Forceps  in  Mento- 
anterior Positions  of  the  Face. 


these  cases  great  care  must  be  taken  to  avoid  injuring  the 
eyes.  The  blades  are  applied  precisely  in  the  same  manner 
as  in  a  vertex  case,  the  grip  of  the  head  which  will  be  obtained 
in  mento-anterior  positions  being  shown  in  Fig.  339. 

Application  of  Forceps  to  the  After-coming  Head. — This 
operation  may  be  performed  when  the  head  is  retained  in  the 
pelvic  cavity  and  digital  methods  of  extraction  have  failed  ;  it 
is  quite  unsuitable  when  the  head  has  not  passed  through  the 
brim.  If  the  occiput  is  anterior,  the  body  of  the  child  is  held 
forwards  against  the  mother's  abdomen,   and  the  forceps 


718  OBSTETRIC   OPERATIONS 

applied  in  the  usual  manner  behind  it.  Extraction  will  be 
easy  unless  the  head  is  extended.  When  the  occiput  is 
posterior,  the  forceps  must  be  applied  in  front  of  the  child's 
body. 

Risks  of  the  Forceps  Operation. — When  strict  antiseptic 
precautions  are  taken,  when  proper  dilatation  of  the  cervix 
has  been  previously  secured,  when  the  conditions  are  favour- 
able as  regards  the  relative  sizes  of  the  pelvis  and  the  foetal 
head,  and  when  extraction  is  practised  with  care  and  skill, 
the  forceps  operation  is  devoid  of  any  serious  risk  to  the 
mother.  In  lying-in  hospitals  it  is  observed  that  the  puer- 
peral morbidity  rate  is  definitely  higher  in  forceps  cases  than 
in  natural  births.  But  this  increase  may  well  be  due  rather 
to  the  prolonged  and  difficult  character  of  the  labour  in  such 
cases  than  to  the  actual  forceps  operation.  Serious  lacera- 
tions of  the  cervix  and  vaginal  vault,  or  of  the  vulva,  may 
however  be  caused  by  inattention  to  the  directions  laid  down 
for  the  use  of  the  instrument  ;  lacerations  in  the  former 
position  are  usually  caused  by  performing  the  operation 
too  early  in  labour  ;  in  the  latter  position  they  may  be  caused 
by  slipping  of  the  blades,  or  by  extraction  after  marked 
rotation  of  the  instrument  has  occurred,  or  in  delivering  an 
unrotated  occipito-posterior  position.  Attempts  to  deliver 
by  forceps  when  there  is  insufficient  pelvic  space  may  cause 
serious  lacerations,  or  from  extreme  or  prolonged  compres- 
sion sloughing  of  some  part  of  the  vaginal  wall  may  subse- 
quently occur.  Extraction  performed  too  rapidly,  or  in  the 
absence  of  uterine  contractions,  may  lead  to  serious  post- 
partum haemorrhage.  To  the  foetus  there  is  much  more  risk 
than  to  the  mother  :  the  foetal  mortality  of  forceps  opera- 
tions during  recent  years  at  Queen  Charlotte's  Hospital  was 
79  deaths  in  1,300  cases,  a  mortahty  of  6  per  cent,  as  com- 
pared with  a  general  foetal  mortality  for  all  cases  of  2-25  per 
cent.  It  must  however  be  recollected  that  in  many  instances 
the  death  of  the  foetus  may  have  been  due  to  the  long  and 
difficult  character  of  the  labour,  rather  than  to  any  actual 
injury  inflicted  by  the  forceps.  A  reference  to  the  list  of 
indications  for  forceps  will  make  this  clear.  In  fatal  cases 
are  frequently  found  such  injuries  to  the  head  as  fracture 
of  the  cranial  bones  with  intra-cranial  haemorrhage,  condi- 
tions which  may  lead  to  cerebral  compression  and  asphyxia. 


CESAREAN   SECTION  719 

Minor  injuries,  such  as  compression  of  the  facial  nerve 
(Bell's  paralysis)  and  effusions  of  blood  under  the  }>eri- 
cranium  (cephalhsematoma),  may  also  be  caused  by  forceps. 

Csesarean  Section 

This  operation  consists  in  the  removal  of  the  foetus  from 
the  uterus  by  abdominal  incision. 

Historical. — Although  Caesarean  section  was  practised 
upon  the  dead  mother  in  very  early  times,  and  was  indeed  so 
prescribed  by  Roman  law,  it  was  not  until  the  Middle  Ages 
that  the  first  operation  was  performed  during  life.  The  first 
recorded  instance  occurred  about  the  year  1500,  when  a 
Swiss  pig-gelder  performed  it  upon  his  own  wife.  The  first 
serious  treatise  upon  the  subject  was  published  in  1581  by 
Rousset.  From  the  sixteenth  to  the  middle  of  the  nine- 
teenth centuries  the  mortality  attending  it  was  so  high  as 
almost  to  prohibit  the  operation  ;  Lepage  states  that  not  a 
single  case  operated  upon  in  Paris  between  1799  and  1877 
recovered.  The  general  mortality  even  in  the  first  half  of 
the  nineteenth  century  is  known  to  have  been  over  50  per 
cent.  There  is  no  wonder  that  craniotomy  and  symphy- 
siotomy were  at  this  time  strongly  advocated  as  alternative 
procedures.  One  of  the  chief  causes  of  the  high  mortality 
was  that  the  uterine  incision  was  not  sutured,  as  at  that  time 
surgeons  believed  that  ligatures  could  not  be  buried  in  the 
abdominal  cavity  owing  to  the  risk  of  their  suppurating  ; 
the  immediate  causes  of  death  were,  no  doubt,  haemorrhage 
and  septicaemia.  The  first  attempts  to  suture  the  uterus 
were  made  in  1835,  but  it  was  not  until  the  introduction  of 
Sanger's  method,  in  1882,  that  any  satisfactory  way  of 
accomplishing  it  was  devised.  To  this  observer  belongs 
most  of  the  credit  for  the  success  which  now  attends 
the  operation.  Sanger's  plan  was  to  employ  two  series 
of  sutures — one  deep,  the  other  superficial  ;  and  no  im- 
portant modification  of  this  method  has  been  since  intro- 
duced. The  elaboration  of  antiseptic  and  aseptic  technique 
during  the  last  quarter  of  a  century  stands  next  in  import- 
ance to  suture  of  the  uterine  wound  as  a  cause  of  the  low 
mortality  of  the  operation  at  the  present  time,  which,  in 
the  hands  of  skilled  operators  and  under  favourable  con- 


720  OBSTETRIC    OPERATIONS 

ditions,  does  not  exceed  3  per  cent.,  while  the  foetal 
mortality  is  about  5  to  6  per  cent. 

An  important  modification  of  the  operation  of  Csesarean 
section  was  introduced  by  Porro  in  1876,  six  years  previous 
to  the  publication  of  Sanger's  method  of  uterine  suture. 
Porro's  operation  consisted  of  amputating  the  body  of  the 
uterus  after  the  extraction  of  the  child,  controlling  the  stump 
with  a  serre-noeud,  and  fixing  it  in  the  lower  angle  of  the 
abdomuial  wound.  It  was  introduced  as  a  means  of  pre- 
venting haemorrhage  and  sepsis,  and  was  not  a  momentary 
inspiration,  but  the  outcome  of  much  consideration  and 
experiment  upon  animals.  He  advocated  its  general  adop- 
tion in  the  place  of  Caesarean  section.  The  expectations 
raised  by  the  new  operation  were  not  generally  realised, 
for  in  1882  Godson  collected  152  cases  with  a  mortahty  of 
56' 57  per  cent.  To  Porro,  however,  belongs  the  great 
credit  of  having  been  the  first  to  conceive  the  idea  of 
removing  the  uterus  after  extracting  the  child.  Porro's 
operation  has  now  been  almost  entirely  abandoned,  but  the 
principle  of  the  removal  of  the  uterus  in  certain  cases  has 
become  well  established,  the  method  adopted  being  usually 
the  modern  one  of  intra-peritoneal  hysterectomy. 

Two  Csesarean  operations,  distinct  from  one  another  in 
principle,  have  therefore  to  be  considered  :  Conservative 
or  ClassirM  Cesarean  Section,  in  which  the  uterus,  after 
being  opened,  is  sewed  up  and  returned  ;  and  Ccesarean 
Hysterectomy,  in  which  the  uterus  is  removed  after  the 
extraction  of  the  child.  Within  recent  years  two  modifica- 
tions of  Conservative  Csesarean  Section  have  been  intro- 
duced ;  their  place  in  obstetric  suygery  is  however,  at 
present,  undefined,  and  therefore  they  need  be  only  briefly 
referred  to. 

A  method  of  extracting  a  full-time  child  per  vaginam  by 
means  of  one  or  more  deep  incisions  into  the  cervix  was 
advocated  by  Diihrssen  in  1895,  and  named  by  him  Vaginal 
Ccesarean  Section.  As  has  been  already  mentioned,  this 
consists  in  the  application  to  obstetrics  of  a  well-known 
gynaecological  procedure.  This  operation  and  the  condi- 
tions under  which  it  may  be  performed  have  been  already 
described  (p.  608).  Still  more  recently  a  different  modifica- 
tion of  Conservative  Csesarean  Section  has  been  introduced, 


CiESAREAN  SECriON  72l 

designed  to  render  the  operation  extra-peritoneal  by  exposing 
and  opening  the  anterior  uterine  wall  below  the  level  of  the 
firm  attachment  of  peritoneum.  This  operation,  known  as 
Extra-peritoneal  Ccesarean  Section,  is  specially  intended  for 
application  to  cases  in  which  the  uterus  has  been  infected, 
or  is  likely  to  have  been  infected,  by  previous  unsuccessful 
attempts  to  deliver  per  vias  naturales.  It  is  supposed  that 
by  this  method  the  risk  of  infecting  the  general  peritoneal 
cavity  when  opening  the  uterus  may  be  avoided.  This 
point  will  be  again  referred  to  in  considering  Csesarean 
section  of  an  infected  uterus. 

Indications. — Owing  to  the  present  low  mortality  of 
Cesarean  section,  the  indications  for  its  performance  have 
been  considerably  extended  in  recent  years.  It  is  now 
performed  under  most  of  the  conditions  which  were  previously 
held  to  necessitate  craniotomy  upon  the  living  child,  and 
it  will  probably  in  time  almost  entirely  replace  symphysio- 
tomy ;  while  owing  to  the  uncertainty  of  the  survival  of  the 
child  after  induction  of  premature  labour,  it  is  encroaching, 
as  has  been  stated  in  another  place,  upon  the  field  of  this 
operation  also.  As  regards  the  maternal  risk,  it  compares 
unfavourably  with  induction  of  premature  labour,  in  which 
there  is  practically  none  ;  but  the  chances  of  the  survival 
of  the  child  in  the  second  degree  of  pelvic  contraction  are 
very  much  greater  by  Ceesarean  section  than  by  induction. 
It  must,  however,  be  understood  that  this  operation  is 
only  justifiable  for  moderate  degrees  of  pelvic  contraction, 
when  it  can  be  performed  with  adequate  preparation  and 
under  favourable  surgical  conditions.  In  the  case  of  patients 
seen  for  the  first  time  when  in  labour,  the  alternatives 
of  craniotomy  and  symphysiotomy  will  sometimes  have  to 
be  considered  even  when  the  child  is  living.  There  is  no 
doubt  that  it  is  better  to  perform  craniotomy  than  to  attempt 
to  deliver  a  living  child  by  Caesarean  section  hurriedly  under- 
taken, with  insufficient  antiseptic  preparations,  in  insanitary 
surroundings,  or  by  an  operator  unaccustomed  to  the  tech- 
nique of  aseptic  surgery.  And  further,  it  may  be  wiser  to 
perform  craniotomy  than  Csesarean  section  when  repeated 
unsuccessful  attempts  have  been  previously  made  to  deliver 
through  the  natural  passages  ;  for  apart  altogether  from 
the  possible  risk  of  infection  having  occurred,  the  chances  of 
E.M.  46 


7.22  OBSTETRIC   OPERATIONS 

the  survival  of  the  child,  even  if  dehvered  alive  by  Csesarean 
section,  have  been  necessarily  prejudiced  by  repeated  and 
prolonged  attempts  to  extract  it  with  forceps  through  a 
narrow  pelvis.  Cranial  injuries  such  as  meningeal  haemor- 
rhage may  thus  be  caused,  from  which  the  child  will  almost 
inevitably  die  in  a  few  days,  even  if  born  ahve.  Inasmuch 
as  tJie  operation  would  be  undertaken  solely  with  the  object 
of  rescuing  the  child,  the  fact  that  its  survival  has  been 
already  gravely  prejudiced  must  not  be  overlooked. 

If  there  are  any  positive  signs  of  infection  having 
occurred,  such  as  offensive  smell  of  the  liquor  amnii,  or 
fever  associated  with  signs  of  illness  or  exhaustion  on  the 
part  of  the  mother,  the  child's  life  should  unhesitatingly  be 
sacrificed,  Csesarean  section  in  such  a  case  bemg  an  extremely 
dangerous  operation.  Intra-uterine  infection  during  labour 
speedily  causes  the  death  of  the  child  from  spread  of  the 
mfection,  and  by  the  time  the  above-mentioned  evidences 
of  infection  are  observed  the  foetal  heart  sounds  have  usually 
ceased. 

It  is  usual  to  divide  the  indications  into  absolute  and 
relative.  In  the  former  a  degree  of  obstruction  is  present 
which  absolutely  prohibits  delivery  by  any  method  through 
the  natural  passages  ;  therefore  Caesarean  section  must  be 
performed  whether  the  foetus  is  dead  or  alive  ;  in  the  latter, 
delivery  by  the  natural  passages,  though  perhaps  difficult, 
is  possible,  and  the  operation  is  resorted  to  from  choice,  not 
necessity. 

Absolute    Indications. — (1)  Extreme    degrees    of    pelvic 
contraction,  the  conjugate  diameter  of  the  brim  being  not 
more  than  2  inches,  or  the  area  of  the  plane  of  the  brim  not 
more  than  2  x  4  inches  (5  X  10  cm.). 
(2)  Insuperable  obstruction  from — 

(a)  Tumours  of  the  uterus,   such  as  cancer  of  the 
cervix,  and  fibroids  of  the  lower  uterine  segment 
or  cervix. 
(6)  Other  tumours,   impacted  in  the  pelvis,   which 
cannot  be  removed  by  vaginal  or  abdominal 
section,  without  first  extracting  the  foetus  from 
the  uterus, 
(c)  Tumours  of  the  pelvic  bones. 
{d)  Undilatable  atresia  of  the  cervix  or  vagina. 


CESAREAN   SECTION  723 

Relative  Indications. — (1)  Certain  degrees  of  'pelvic  con- 
traction or  of  obstruction  from  other  causes,  as  an  alternative 
to  craniotomy,  symphysiotomy,  or  induction  of  premature 
labour  (conjugate  of  the  brim  from  2  to  3|  inches — 4  to 
8-75  cm.). 

(2)  Fibroid  Tumours  which  threaten  to  cause,  or  are 
actually  causing,  some  degree  of  obstruction  in  labour.  In 
addition  to  overcoming  an  obstruction,  Csesarean  section 
gives  an  opportunity  of  dealing  at  the  same  time  with  the 
fibroid  tumour.  The  ideal  procedure  is  to  enucleate  the 
fibroids  from  the  uterine  wall,  after  extracting  the  child, 
and  then  to  close  the  incisions  and  conserve  the  uterus. 
This  is,  however,  not  always  practicable,  and  removal  of 
the  uterus  must  then  be  carried  out. 

Ovarian  tumours  obstructing  labour  may  be  dealt  with  by 
Csesarean  section.  If  the  tumour  is  fixed  in  the  pelvis,  it 
may  be  impossible  to  separate  and  remove  it  without  first 
reducing  the  size  of  the  uterus  by  extracting  the  child. 
The  ideal  procedure  in  such  eases  is  to  remove  the  tumour 
first,  and  then  to  deliver  jper  vagina  without  opening  the 
uterus. 

(3)  Urgent  maternal  complications  sometimes  call  for 
delivery  by  Csesarean  section.  Reference  has  been  already 
made  to  its  use  in  eclampsia,  in  placenta  prsevia,  in  accidental 
haemorrhage,  and  in  heart  disease.  In  some  of  these  con- 
ditions, e.g.,  in  eclampsia  and  in  heart  disease,  the  use  of  a 
general  anaesthetic  constitutes  one  of  the  chief  risks  of  the 
operation,  and  one  of  the  great  objections  to  it.  Some 
method  of  local  anaesthesia  should  therefore  be  employed 
whenever  possible  ;  the  spinal  method  is  suitable,  or  if  the 
operator  is  unfamiliar  with  the  technique  of  this  procedure, 
the  so-called  "  shockless  method  "  of  Crile  maybe  made  use 
of.  This  consists  in  infiltrating  the  abdominal  wall  with  a 
weak  solution  of  novocain  and  quinine -urea-hydrochloride, 
which  destroys  sensation  and  produces  complete  muscular 
relaxation  in  the  infiltrated  area.  A  very  small  amount 
of  a  general  anaesthetic  is  usually  combined  with  it,  sufficient 
to  suspend  consciousness. 

(4)  Death  of  the  mother,  the  operation  being  undertaken 
immediately  after  death  for  the  purpose  of  extracting  a 
living  child. 

46—2 


724  OBSTETRIC   OPERATIONS 

Ceesarean  section  during  labour  should  not  be  performed 
if  the  conditions  indicate  that  the  survival  of  the  child  is 
unlikely — e.g.,  marked  slowing  of  the  foetal  heart  (under  100), 
or  fixation  with  marked  moulding  of  the  head  in  a  contracted 
brim.  In  the  former  case  it  is  very  unlikely  that  the  child 
will  be  extracted  in  time  to  save  it  since  it  has  either  been 
seriously  injured  or  has  become  deeply  asphyxiated  ;  in  the 
latter  the  extent  of  the  injury  the  head  has  sustained  is 
probably  serious  and  the  survival  of  the  child  doubtful. 
When,  in  addition  to  evidence  of  foetal  injury  or  asphyxia, 
there  is  also  a  probability  of  infection  having  occurred, 
Csesarean  section  must  be  held  to  be  contra-indicated.  To 
expose  the  mother  to  the  increased  risk  associated  with  the 
operation  under  these  conditions,  when  the  survival  of  the 
child  is  already  prejudiced,  is  not  justifiable  ;  the  old 
obstetric  principle  should  be  followed  that  when  the  chances 
of  life  of  the  mother  and  those  of  the  child  are  definitely 
conflicting,  the  child  should  be  sacrificed. 

Indications  for  Removing  the  Uterus. — After  Csesarean 
section  removal  of  the  uterus  may  be  necessitated  by  the 
following  conditions  : 

(1)  Uterine  infection.  It  is  a  wise  precaution  to  remove 
the  uterus  whenever  there  is  reason  to  believe  that  the 
uterine  cavity  has  become  infected.  The  reason  for  re- 
moving the  uterus  lies  in  the  great  risk  of  septic  peritonitis 
which  the  mother  runs  if  the  infected  organ  is  left.  It  is 
quite  practicable,  by  careful  technique,  to  avoid  infecting 
the  general  peritoneal  cavity  with  liquor  amnii,  etc.,  during 
the  operation  {vide  infra).  But  if  the  uterine  tissues  are 
infected  the  incision  in  the  uterus  will  not  heal,  infective 
material  will  pass  into  the  peritoneal  cavity,  and  general 
peritonitis  will  result.  In  some  such  cases  localised  suppura- 
tion has  occurred  between  the  anterior  uterine  wall  and 
the  abdominal  parietes,  resulting  in  a  utero -parietal  fistula. 
When  infection  of  the  parturient  uterus  occurs  it  is  probable 
that  the  infection  is  not  for  long  limited  to  the  amniotic 
cavity,  but  rapidly  spreads  to  the  tissues  of  the  uterine  wall 
itself.  The  danger  of  peritoneal  infection  is  therefore  not 
confined  to  the  operation,  but  remains  when  the  uterus  has 
been  sewn  up  and  returned  to  the  abdomen. 

(2)  Disease  of  the  uterus,  such  as  malignant  or  fibroid 


CESAREAN   SECTION  725 

tumours,  or  malformation,  for  which  hysterectomy  would  be 
indicated  under  any  circumstances. 

(3)  The  uterus  may  be  removed  along  with  the  appen- 
dages in  osteomalacia. 

(4)  When  insuperable  and  incurable  obstruction  is 
present,  for  the  purpose  of  preventing  subsequent  concep- 
tion. 

The  Operation. — When  it  is  necessary  to  perform  the 
operation  hurriedly,  owing  to  the  cause  of  obstruction  being 
undiscovered  until  labour  is  advanced,  the  prognosis  is  dis- 
tinctly less  favourable  than  when  sufficient  time  is  available 
for  proper  preparations  to  be  made.  The  gravity  of  the 
prognosis  may  be  said,  under  such  circumstances,  to  be 
influenced  chiefly  by  the  duration  of  labour  and  the  risk  of 
the  uterus  having  been  infected.  We  have  here  another 
illustration  of  the  importance  in  pelvic  contraction  of  making 
an  accurate  diagnosis  of  the  degree  of  contraction,  so  that 
harm  may  not  be  done  by  resort  to  methods  of  delivery  which 
cannot  possibly  be  successful.  Naturally  also  the  longer 
the  patient  has  been  in  labour  the  more  unfavourable  becomes 
the  prognosis  for  the  child.  It  was  formerly  thought  neces- 
sary to  wait  for  the  onset  of  labour  pains  and  the  com- 
mencement of  dilatation  of  the  cervix,  but  experience  has 
shown  that  there  is  no  advantage  in  so  doing.  When  the 
operation  is  performed  before  labour  has  begun,  some  opera- 
tors advise  that  the  cervix  should  be  artificially  dilated 
until  three  fingers  can  be  passed  through  the  internal  os  in 
order  to  provide  a  channel  for  the  free  escape  of  the  lochia. 
Experience  has  abundantly  shown  that  this  is  quite  unneces- 
sary ;  the  amount  of  lochia  is  usually  small,  and  the  after- 
pains  which  follow  the  operation  accomplish  all  the  cervical 
dilatation  which  is  required.  The  prognosis  is  best  both  for 
mother  and  child  when  the  operation  is  performed  without 
waiting  for  the  onset  of  labour,  and  when  there  is  ample  time 
for  proper  preparations  to  be  made. 

The  general  preparations  necessary  are  those  ordinarily 
required  for  abdominal  section. 

The  local  preparations  include  the  vagina  and  the  abdo- 
minal wall.  Preparation  of  the  vagina  is  unnecessary  when 
the  paits  are  healthy  and  labour  has  not  commenced  ; 
when  labour  has  been  already  for  some  time  in  progress 


726  OBSTETRIC   OPERATIONS 

the  canal  should  be  disinfected  as  for  a  vaginal  operation. 
Preliminary  antiseptic  douching  is  useful,  but  reliance  must 
be  placed  chiefly  on  careful  swabbing  of  the  cervix  and 
vaginal  walls  with  tincture  of  iodine.  This  should  be  done 
with  the  aid  of  a  speculum,  and  may  be  repeated  immediately 
before  the  operation  is  begun.  The  surfaces  must  be  wiped 
free  from  their  secretions  with  pledgets  of  sterile  cotton  wool 
before  applying  the  iodine. 

The  skin  of  the  abdominal  parietes  should  be  sterilised 
from  twelve  to  twenty-four  hours  before  the  operation,  and 
carefully  protected.  When  the  operation  is  performed  as  an 
emergency,  the  following  method  will  suffice  :  After  shaving 
down  to  the  pubes,  the  skin  is  well  scrubbed  with  soft  soap 
and  hot  water  for  five  minutes,  special  attention  being  paid  to 
the  umbilicus  ;  the  soap  is  then  washed  off  with  fresh  hot 
water,  and  ether  poured  over  the  skin  and  rubbed  in  with  a 
swab.  When  the  skin  is  dry  it  is  thoroughly  swabbed  with 
tincture  of  iodine. 

The  best  anaesthetic  is  chloroform,  which  is  particularly 
well  borne  by  pregnant  women,  and  affects  the  foetus  less 
profoundly  than  ether,  owing  to  its  lower  diffusibihty.  An 
intra-muscular  injection  of  ergotin  or  aseptic  ergot  may  be 
made  into  the  buttock  as  soon  as  the  patient  is  anaesthe- 
tised ;  this  will  assist  proper  retraction  of  the  uterus  after  its 
evacuation.  Before  commencing  the  operation  the  pre- 
sentation and  position  of  the  foetus  should  be  determined  by 
palpation,  and  evidence  obtained  that  it  is  alive,  as  Csesarean 
section  for  '  relative  '  indications  is  only  justifiable  when 
the  foetus  is  living.  An  extra  assistant  should  be  at  hand, 
and  a  warm  bath  prepared,  to  resuscitate  the  foetus  if  it 
should  prove  to  be  asphyxiated. 

The  abdominal  incision  should  be  made  about  5  inches 
long  in  the  middle  line,  starting  about  2  inches  above  the 
umbilicus  (Fig.  345).  It  will  be  recollected  that  the  abdo- 
minal parietes  at  term  are  very  thin,  and  the  incision  must 
be  made  with  care,  or  all  the  layers  may  be  unexpectedly 
divided  by  the  first  cut.  Under  normal  conditions  liquor 
amnii  is  sterile,  and  its  escape  need  not  be  feared.  When 
operating  during  labour  precautions  should  be  taken  against 
peritoneal  contamination  by  packing  gauze  between  the 
uterus  and  the  abdominal  wall  all  round  the  incision. 


CESAREAN  SECTION 


727 


The  uterine  incision  should  be  about  4  inches  long,  and  as 
nearly  as  possible  in  the  mesial  plane  of  the  uterus  (Fig.  344). 


Fig.  340. — Csesarean  Section.  Extracting  the  child  by  the  feet;  the 
operator's  left  hand  is  assisting  the  delivery  of  the  head  ;  the  uterus 
is  being  steadied  by  the  two  hands  of  an  assistant. 

It  is  therefore  advisable  to  insert  the  hand  and  rotate  the 
uterus  if  it  is  obvious  that  its  anterior  surface  lies  obliquely. 
The  uterine  incision  should  be  made  to  correspond  with  the 
upper  4  inches  of  the  abdominal  incision  ;  this  will  avoid  the 


728 


OBSTETRIC   OPERATIONS 


lower  uterine  segment  altogether,  and  there  will  be  no  risk  of 
injuring  the  bladder.  Free  haemorrhage  will  usually  occur, 
which,  however,  may  be  neglected  for  the  moment.  The 
membranes  should  be  first  ex]30sed  by  a  smaU  incision, 
which  can  be  extended  by  dividing  the  uterme  wall  upwards 
and  downwards  with  scissors  ;  the  amniotic  sac  is  then 
opened  and  the  hand  passed  to  the  breech,  the  position  of 
which  has  been  previously  determined  by  palpation.     The 


Fig.  341. — Cfesarean  Section.      The  child  has  been  extracted,  and  the 
alter-bii'th  is  being  squeezed  out  of  the  uterus. 

foetus  is  then  seized  by  the  feet  and  delivered  breech  first 
(Fig.  340)  ;  the  cord  is  immediately  clamped  and  divided, 
and  the  child  handed  over  to  the  care  of  an  assistant.  If  the 
placenta  lies  ujDon  the  anterior  wall  jarofuse  bleeding  will 
occur  from  the  first  cut  in  the  uterus,  but  without  pausing 
the  operator  should  tear  through  the  placental  tissues  with 
two  forefingers,  open  the  amnion  and  extract  the  child  as 
rapidly  as  possible,  when  the  haemorrhage  can  be  brought 
under  control.     This  is  a  much  more  rapid  method  than  the 


CESAREAN  SECTION 


729 


plan  usually  recommended  of  detaching  the  placenta  on  both 
sides  of  the  incision  and  pulling  it  out  of  the  wound  before 
extracting  the  child.  Until  the  child  has  been  extracted  the 
operator  must  work  rapidly,  for  loss  of  time  involves  not 
only  free  bleeding  but  also  risks  of  foetal  asphyxia. 

As  soon  as  the  child  has  been  extracted  the  operator's 
assistant  passes  his  hand  behind  the  fundus,  turns  the  re- 


FiG.  342. — Csesarean  Section.     Squeezing  the  uterus  through  a  hot 
sterilised  towel  to  promote  contraction. 


tracted  uterus  out  of  the  abdominal  wound,  and  squeezes 
it  firmly  in  a  hot  towel  to  control  bleeding.  The  intestines 
are  then  protected  with  sterilised  towels  or  large  swabs,  and 
the  placenta  and  membranes  carefully  and  completely  peeled 
off  the  uterine  wall.  If  labour  has  not  commenced,  the 
finger  should  be  passed  through  the  cervix,  to  see  that 
there  is  sufficient  space  for  free  drainage  of  the  lochia. 

Closing  the   Uterine  Incision. — Free  haemorrhage  occurs 
from  the  cut  surfaces  of  the  uterine  wall  in  which  large 


730 


OBSTETRIC   OPERATIONS 


venous  sinuses  and  sometimes  arteries  of  considerable  size 
have  been  divided.  This  haemorrhage  can  be  temporarily- 
arrested  by  wrapping  up  the  uterus  in  a  sterilised  towel 
wrung  out  of  hot  saline  solution,  and  then  moulding  it 
firmly  between  the  hands  as  shown  in  Fig.  342.  This  pro- 
duces fairly|good  retraction  of  the  uterine  muscle  by  which 


Fig.  343. — Ceesarean  Section.     The  deep  sutures  have -been  introduced, 
but  only  the  top  one  has  been  tied. 

the  bleeding  is  to  a  great  extent  controlled  ;  the  effect  lasts 
for  two  or  three  minutes,  during  which  sutures  can  be  intro- 
duced, and  the  manipulation  of  the  uterus  can  then  be  re- 
peated if  necessary.  Bleeding  can  also  be  controlled  to  some 
extent  by  placing  a  pair  of  intestinal  clamps  on  each  broad 
ligament,  outside  the  ovary,  as  soon  as  the  uterus  has  been 
turned  out  of   the    abdomen.     It    is,  however,  difficult  to 


CESAREAN   SECTION 


731 


effectually  compress  the  uterine  arteries  owing  to  the  depth 
at  which  they  lie,  and  the  former  method  will  be  found  more 
effectual. 

Suturing  the  uterine  incision  is  the  most  important  step 
in  the  operation,  and  it  must  be  carefully  carried  out.  The 
method  of  Sanger  is  in  general  use  for  this  purpose.     Two 


Fig.  344. — Oaesarean  Section.     The  uterus  has  been  closed  with 
alternate  deep  and  superficial  sutures. 

series  of  sutures  are  employed,  the  deep  and  the  superficial. 
The  deep  sutures  are  placed  at  intervals  of  about  three- 
quarters  of  an  inch,  the  two  end  stitches  including  the 
angles  of  the  incision.  Each  suture  may  be  made  to  include 
the  whole  thickness  of  the  uterine  wall,  being  introduced 
about  one-third  of  an  inch  outside  the  cut  edge  on  the 
peritoneal  surface,  and  made  to  emerge  on  the  uterine 
surface  near  the  edge  of  the  incision  (Fig.  343)  ;  the  needle 


732  OBSTETRIC   OPERATIONS 

is  then  re-introduced  upon  the  uterine  surface  of  the  opposite 
side  and  brought  out  at  a  point  about  one-third  of  an 
inch  outside  the  cut  edge  on  the  peritoneal  surface.  When 
tied  this  suture  will  firmly  approximate  the  cut  surfaces 
through  their  whole  thickness.  The  sutures  may  be  tied 
one  by  one  as  they  are  introduced,  or  the  whole  series  of 
deep  stitches  may  be  introduced  before  any  are  tied. 
The  latter  method  allows  of  the  cut  edges  being  everted 
and  held  together  by  an  assistant  while  the  sutures  are 
being  introduced.  The  deep  stitches  must  be  firmly  tied 
so  as  to  produce  considerable  tension  (Eig.  344). 

After  the  deep  stitches  have  been  tied,  the  uterus  should 
again  be  manipulated  with  a  hot  towel  to  produce  retraction, 
and  the  superficial  stitches  can  then  be  introduced.  One  or 
two  may  be  required  in  each  interval  between  the  deep 
stitches.  They  should  be  made  to  take  up  about  half  the 
thickness  of  the  uterine  wall,  and  should  be  tied  with  as 
little  tension  as  possible. 

The  ideal  suture  material  is  catgut  specially  hardened  by 
the  chromic  acid  or  the  formalin-iodine  process.  A  stout 
ligature  is  required  for  the  deep  sutures  (No.  4),  and  a  finer 
one  for  the  intermediate  sutures  (No.  2).  Silk  or  thread 
may,  however,  be  used  instead  of  catgut. 

Closure  of  the  Abdominal  Wound. — The  uterus  is  now 
returned  to  the  abdominal  cavity,  and  all  blood  or  other 
fluid  must  be  cleared  away  from  the  flanks  and  the  pouch  of 
Douglas,  or  wherever  it  may  be  found.  Before  returning  it, 
the  uterus  should  be  again  firmly  squeezed  in  a  hot  sterilised 
towel  to  expel  any  blood  from  the  cavity  which  may  have 
accumulated  during  the  suturing  of  the  incision.  If  the 
uterus  does  not  retract  properly  it  can  be  massaged,  or  hot 
sterile  saline  solution  (0-75  per  cent.)  poured  over  it.  It  is 
preferable,  if  possible,  to  sew  up  the  abdominal  wound  in 
three  layers,  in  the  usual  manner  ;  but  owing  to  the  thin- 
ness of  the  parietes  this  is  not  always  practicable.  The 
peritoneum  may  then  be  closed  with  a  continuous  catgut 
suture,  and  the  other  layers,  including  the  aponeurosis  and 
the  skin,  taken  up  with  interrupted  silk  or  silkworm-gut 
stitches. 

The  technique  just  described  is  suitable  for  all  cases  in 
which  the  operation  is  performed  before  labour,  or  early  in 


CESAREAN   SECTION 


733 


labour,  when  there  is  no  risk  of  infection  having  occurred. 
When  the  operation  is  performed  after  labour  has  been 
already  prolonged,  or  after  unsuccessful  attempts  to  deliver 
with  forceps  have  been  made,  stringent  precautions  should 
be  taken  to  avoid  infecting  the  general  peritoneal  cavity 
when  emptying  the  uterus.  The  technique  of  the  operation 
should  then  be  modified  in  the  following  manner  : 

The  parietal  incision  should  be  prolonged  upwards  to  a 
length  of  about  8  inches,  when  the  entire  uterus  can  be  even- 
trated  through  it.     The  abdominal  cavity  is  then  carefully 


Fig.  345. — Ceesarean  Section.     The  closed  abdominal  incision. 


packed  off  with  sterilised  towels  and  large  abdominal  pads 
wrung  out  of  warm  sterile  saline  solution.  Similarly  the 
utero-vesical  pouch  and  lateral  pelvic  regions  are  packed, 
and  the  edges  of  the  abdominal  wound  protected  in  the  same 
manner.  The  uterus  can  then  be  opened  either  by  a  median 
anterior  incision  placed  rather  higher  up  than  that  just 
described,  or  by  a  transverse  incision  across  the  fundus 
(incision  of  Fritsch).  After  emptying  the  uterus,  the  uterine 
cavity  may  be  swabbed  out  with  weak  lysol  solution  (5j.  to 
Oj.),  and  the  incision  then  closed  by  Sanger's  method.  The 
surface  of  the  uterus  is  next  freely  irrigated  with  normal 


734  OBSTETRIC   OPERATIONS 

saline  solution,  the  packing  is  removed,  and  the  uterus 
allowed  to  drop  back  into  the  abdominal  cavity.  Finally 
the  operator  and  his  assistant  put  on  a  fresh  pair  of  boiled 
rubber  gloves,  and  a  fresh  set  of  instruments  should  be  used 
in  closing  the  abdominal  wound. 

Sterilisation  of  the  Patient. — It  is  seldom  justifiable  to 
sterilise  a  patient  after  conservative  Caesarean  section.  This 
operation  has  now  been  performed  with  success  as  many  as 
five  times  upon  the  same  patient,  and  the  risks  attending 
it  are  so  small  that  permanent  mutilation  in  order  to  avoid 
the  risk  of  a  second  operation  should  be  discouraged.  Preg- 
nancy following  Csesarean  section  usually  runs  a  normal 
course  ;  in  very  rare  instances  spontaneous  rupture  through 
the  uterine  cicatrix  either  before  or  during  labour  has 
been  reported.  (Fig.  243.)  Sterilisation  is  therefore  rarely 
required,  except  for  local  incurable  disease. 

Sometimes,  however,  it  may  be  necessary  to  sterilise  a 
healthy  woman  from  unwillingness  on  her  part  to  undergo 
operation  again.  This  may  be  accomplished  either  by 
removing  the  uterus  or  by  removing  the  whole  of  both 
Fallopian  tubes.  The  removal  of  the  ovaries  for  this  pur- 
pose is  unjustifiable  unless  these  organs  are  grossly  diseased, 
or  the  patient  is  the  subject  of  osteomalacia,  for  double 
oophorectomy  is  often  followed  by  serious  consequences  in 
women  under  forty-five  years  of  age.  The  removal  of  the 
uterus  is  objectionable  in  women  less  than  forty-five 
years  of  age,  inasmuch  as  it  involves  permanent  arrest  of 
menstruation.  The  removal  of  the  Fallopian  tubes  has  no 
influence  whatever  upon  the  menstrual  functions.  It  is 
necessary  to  remove  them  in  their  entirety  to  ensure 
sterility,  and  to  close  the  peritoneum  over  the  stump  at  the 
uterine  end.  It  has  been  shown  that  ligation  of  the  tubes 
alone,  or  ligation  and  division,  or  even  excision  of  a  portion 
of  the  tubes,  may  be  followed  by  conception,  through  sub- 
sequent restoration  of  the  tubal  lumen. 

The  after-treatment  of  Csesarean  section  is  much  the  same 
as  that  of  abdominal  section  generally.  The  skin  sutures 
should  be  removed  on  the  tenth  day,  and  the  patient  should 
be  kept  in  bed  for  two  to  three  weeks.  The  amount  of 
lochial  discharge  is  usually  small,  and  the  involution  of  the 
uterus  is  not  unfavourably  affected.     The  patient  may  be 


PLATE    V 


Uterus  removed  by  Ctesarean  Hysterectomy  for  Cancer  oi  the  Cervix. 
Placenta  in  situ.  Below  is  a  portion  of  the  growth  which  whs 
removed  prior  to  the  operation.  (From  the  collection  of  Dr. 
Cuthbert  Lockyer.) 


CESAREAN   HYSTERECTOMY  735 

quite  able  to  suckle  her  child,  and  should  be  encouraged  to 
do  so. 

Caesarean  Hysterectomy. — This  operation  is  performed 
in  the  same  way  as  conservative  Csesarean  section  up  to 
the  point  of  extraction  of  the  foetus.  The  uterus  may 
then  be  amputated  at  the  level  of  the  internal  os,  or  the 
whole  organ,  body  and  cervix,  may  be  removed. 

Supra-vaginal  Amputation. — The  ovarian  vessels  on  each 
side  are  first  secured  with  two  ligatures,  so  as  either  to 
remove  or  to  leave  the  ovaries  as  may  be  desired  ;  in  patients 
under  forty-five  both  ovaries,  if  healthy,  should  be  left. 
Then  the  round  ligaments  are  similarly  ligatured.  The  broad 
ligaments,  first  one  and  then  the  other,  are  clamped  close  to 
the  uterine  border,  and  divided  between  the  clamp  and  the 
ovarian  ligature  down  to  the  level  of  the  internal  os.  Next 
an  anterior  peritoneal  flap  is  mapped  out  and  turned  down 
along  with  the  bladder  ;  this  allows  the  uterine  arteries  to 
be  secured  and  divided  at  the  level  of  the  internal  os  close  to 
the  uterine  wall.  The  uterus  is  then  amputated  ;  after  the 
uterine  arteries  have  been  tied  and  all  oozing  from  the  stump 
has  been  stopped,  the  peritoneal  edges  are  united  over  it  by  a 
continuous  suture  running  from  one  ovarian  artery  across 
the  pelvic  floor  to  the  other. 

Panhysterectomy. — This  operation  is  performed  in  the 
manner  just  described  up  to  the  point  of  securing  and  divid- 
ing the  uterine  arteries.  The  cellular  tissue  is  then  pushed 
down  all  round  the  cervix  until  the  reflection  of  the  vaginal 
vault  is  reached.  The  anterior  vaginal  fornix  is  then  opened 
with  knife  or  scissors  and  the  incision  carried  completely 
around  the  cervix,  when  the  uterus,  being  freed,  can  be 
lifted  out.  All  oozing  from  the  cut  edges  of  the  vaginal  wall 
must  be  carefully  controlled  ;  a  gauze  pad  is  then  pushed 
down  into  the  vagina,  and  the  peritoneum  closed  over  it 
with  a  continuous  suture  from  one  ovarian  artery  to  the 
other. 

Supra-vaginal  amputation  is  preferred  by  most  operators, 
but  total  hysterectomy  will  be  required  for  septic  infection 
of  the  uterus  or  for  malignant  growths  of  the  cervix 
(Plate  v.),  and  in  some  cases  for  fibroids. 

Vaginal  Caesarean  Section. — This  operation  consists  in 
extracting  a  viable  child  through  an  undilated  cervix  by 


736  OBSTETRIC   OPERATIONS 

means  of  one  or  more  deep  incisions  extending  into  the 
lower  uterine  segment.  It  has  been  already  mentioned  as  a 
method  of  accouchement  force.  It  is  not  available  in  cases 
of  pelvic  contraction  or  any  other  form  of  obstruction, 
consequently  its  utility  is  greatly  Limited  in  comparison  with 
abdominal  methods  of  opening  the  uterus.  It  has  been 
employed  chiefly  in  cases  of  eclampsia,  and  was  indeed 
introduced  by  Diihrssen  as  a  method  of  dealing  with  that 
complication. 

The  technique  of  the  operation  is  more  difficult  than  that 
of  abdominal  Caesarean  section,  and  it  is  very  doubtful 
whether  there  are  any  compensating  advantages.  When  the 
foetus  is  small,  e.g.  up  to  the  thirtieth  week,  the  difficulties 
are  of  course  much  smaller.  Inasmuch  as  the  cases  in 
which  it  has  been  performed  have  been,  as  a  rule,  cases  of 
eclampsia  of  great  severity,  the  apparent  mortaUty  of  the 
operation  is  very  high.  But  it  must  be  recollected  that  in 
such  cases  death  would  be  very  likely  to  occur  from  toxaemia 
quite  independently  of  the  method  of  dehvery  adopted. 

Extra-peritoneal  C cesarean  Section. — This  new  and  com- 
paratively untried  procedure  consists  in  reflecting  the  peri- 
toneum from  the  lower  part  of  the  anterior  surface  of  the 
uterine  wall,  and  then  extracting  the  child  through  a  trans- 
verse incision  through  the  lower  uterine  segments.  The 
general  peritoneal  cavity  is  not  opened,  or  if  opened  is  again 
closed  before  making  the  uterine  incision,  by  stitching  the 
reflected  peritoneal  flap  to  the  parietal  peritoneum  as  high  up 
as  possible.  It  was  designed  to  avoid  the  risk  of  peritoneal 
infection  when  opening  an  infected  uterus  by  the  classical 
method  of  Csesarean  section. 

Prognosis  of  the  C cesarean  Operations. — From  statistics  of 
cases  of  Csesarean  section  by  British  operators  collated  by 
Amand  Routh,  it  appears  that  the  mortality  of  the  operation 
during  the  five  years  1906  to  1910  was  6*1  per  cent.,  as 
estimated  from  602  operations.  This  represents  the  general 
maternal  mortality  which  follows  the  operation  as  performed 
at  the  present  time.  But  it  must  be  recollected  that  the 
whole  of  this  mortality  is  not  due  to  the  operation  ;  a  part 
must  be  attributed  to  pre-existing  maternal  complications, 
or  to  other  unfavourable  conditions  which  were  present.  It 
has  been  already  mentioned  that  when  the  operation  is 


CESAREAN   SECTION  737 

performed  late  in  labour,  and  after  unsuccessful  attempts  to 
deliver  with  forceps  have  been  made,  the  prognosis  is  not  so 
favourable  as  when  the  operation  is  performed  before  labour. 
This  point  is  illustrated  by  Routh's  statistics,  which  show 
that  469  cases  operated  on,  either  before  labour,  or,  at  any 
rate,  before  rupture  of  the  membranes,  had  a  mortality  of 
only  2-9  per  cent. — i.e.,  less  than  one-half  of  the  mean  mor- 
tality of  the  whole.  But  230  cases  operated  on  after  rupture 
of  the  membranes,  and  in  some  cases  after  prolonged  labour, 
showed  a  mortality  of  17-3  per  cent. 

Further,  it  will  be  obvious  that  Csesarean  section  for 
grave  maternal  disorders  such  as  eclampsia  must  necessarily 
yield  a  percentage  of  mortality  greatly  in  excess  of  the  true 
mortality  of  the  operation. 

The  foetal  mortality,  which  is,  of  course,  influenced  to 
some  extent  by  the  same  considerations,  is  placed  by  Routh 
at  about  8  per  cent. 

Craniotomy,  Decapitation,  and  Evisceration 

These  operations  are  designed  to  reduce  the  bulk  of  the 
foetal  head  or  trunk  so  as  to  allow  of  its  extraction  through 
the  genital  canal.  Recent  improvements  in  other  obstetric 
operations  have  greatly  restricted  the  indications  for 
destruction  of  the  foetus  in  utero,  and  there  is  now  a  general 
agreement  that  the  destructive  operations  should  not  be 
performed  upon  a  living  foetus,  unless  the  circumstances  of 
the  case  render  any  alternative  procedure  positively  danger- 
ous to  the  life  of  the  mother.  They  will,  of  course,  continue 
to  hold  their  position  as  the  safest  means  of  delivering  a 
dead  foetus  in  certain  degrees  of  pelvic  contraction,  or  in 
other  forms  of  obstruction  or  difficult  delivery.  In  the  case 
of  a  living  foetus  the  alternative  procedures  of  symphy- 
siotomy and  Csesarean  section  should  be  carefully  considered, 
and  only  when  the  circumstances  of  the  case  are  such  as  to 
increase  greatly  the  average  risk  of  these  operations  can  it  be 
justifiable  to  destroy  a  living  foetus  in  order  to  deliver  it. 

A.  Craniotomy. — This  term  includes  the  various  methods 
of  reducing  the  size  of  the  foetal  head. 

Indications. — (a)  Obstruction  of  extreme  degree,  from 
pelvic  contraction,  from  atresia,  or  from  tumours  of  the  soft 
E.M.  47 


738  OBSTETRIC   OPERATIONS 

parts,  when  the  child  is  dead  or  Caesarean  section  is  refused 
or  is  unlikely  to  succeed  in  saving  the  child's  life.  Unless 
the  conjugate  of  the  brim  is  at  least  2|  inches,  extraction 
of  a  fuU-time  foetus  is  always  very  difficult  ;  if,  however, 
as  in  a  flat  pelvis,  the  transverse  diameter  is  relatively  long, 
success  may  be  obtained  with  a  conjugate  of  rather  less 
than  2^  mches.  It  is  generally  agreed  that  craniotomy  should 
not  be  attempted  unless  the  pelvic  brim  measures  at  least 
2  inches  by  4  inches  (6-5  cm.  by  10  cm.).  (6)  Conditions 
under  which  delivery  by  forceps  or  version  would  be  prac- 
ticable, but  difficult,  and  the  foetus  is  dead.  As  examples 
may  be  mentioned,  an  impacted  shoulder  presentation, 
irreducible  posterior  positions  of  the  occiput  in  vertex  and 
breech,  or  of  the  chin  in  face  presentations,  (c)  MaKorma- 
tions  of  the  foetal  head,  such  as  hydrocephalus,  (d)  Urgent 
maternal  complications  necessitating  rapid  delivery  with 
the  minimum  of  maternal  risk — e.g.,  eclampsia  and  haemor- 
rhage. 

When  the  indications  for  craniotomy  arise,  the  patient's 
general  condition  has  usually  suffered  from  prolonged 
labour,  and  vaginal  and  perineal  lacerations  are  also  often 
met  with  from  previous  unsuccessful  attempts  to  deliver 
with  forceps.  In  these  circumstances  septic  infection  is 
liable  to  occur,  and  stringent  antiseptic  ]3recautions  should 
accordingly  be  taken.  The  vulva  should  be  shaved,  and 
the  vaginal  canal  and  vulva  thoroughly  cleansed,  first  with 
liquid  soap  and  hot  water,  and  then  with  an  antiseptic 
solution  of  moderate  strength,  such  as  biniodide  of  mercury 
1-2,000,  or  lysol  5j.  to  Oj.  The  bladder  should  then  be 
emptied  by  catheter,  and  the  operator  should  wear  sterilised 
rubber  gloves. 

The  operation  of  craniotomy  consists  of  the  two  stages  of 
(1)  Perforation  ;    (2)  Crushing  and  Extraction. 

(1)  Perforation. — This  stage  consists  in  opening  the 
cranial  cavity  and  evacuating  its  contents.  The  instrument 
required  is  the  ^perforator  ;  many  varieties  are  obtainable, 
but  the  most  useful  is  that  of  Oldham  (Fig.  346).  The  blades 
of  this  perforator  end  in  a  sharp  point,  and  are  each  furnished 
with  an  outer  sharp  cutting  edge  about  1  inch  in  length, 
ending  in  a  projecting  ridge  or  shoulder.  The  blades  them- 
selves   are    straight    and    furnished    with    strong    handles, 


PERFORATION 


739 


separated  widely  from  one  another  when  the  blades  are 
closed.  When  the  handles  are  pressed  together  the  cutting 
edges  are  forced  apart. 

In  perforating  the  fore-coming  head  the  parietal  bone 
should  be  selected  for  the  operation  ;  in  the  case  of  the  after- 


-  Point 


Cutting- 
edge 


Fig.  346. — a,  How  to  hold  the  Perforator  when  closed ; 
h,  How  to  open  the  Perforator. 

Note. — Gloves  should  as  a  rule  be  worn  in  using  this  instrument. 


coming  head  it  is  usually  most  convenient  to  perforate  the 
occipital  bone.  In  the  case  of  a  face  presentation  it  may  be 
necessary  to  perforate  the  roof  of  the  mouth  or  the  orbit.  The 
instrument,  with  blades  closed,  is  held  firmly  in  the  crook  of 
the  handles  (Fig.  346,  a)  and  the  fingers  of  the  other  hand  are 
passed  up  to  the  spot  selected  for  perforation  ;  the  instru- 
ment is  then  introduced  along  the  palm  of  this  hand,  care 

47—2 


740  OBSTETRIC   OPERATIONS 

being  taken  to  protect  the  vaginal  walls  from  the  cutting 
edges.  An  assistant  is  required  to  immobilise  the  head  by 
suprapubic  pressure  when  it  is  not  fixed  in  the  brim.  The 
point  is  then  firmly  pressed  against  the  head,  and  by  a  rotary 
movement  is  made  to  penetrate  the  bone  until  arrested  by 
the  shoulders  of  the  perforator.  Care  must  be  taken  to 
prevent  the  point  from  slipping,  the  fingers  of  the  internal 
hand  keeping  it  in  contact  with  the  head.  The  grip  is  then 
transferred  to  the  handles,  and  as  these  are  forced  together 
the  bone  is  lacerated  by  the  cutting  edges,  two  fingers  of 
the  internal  hand  being  kept  in  contact  with  the  shoulders 
(Fig.  346,  b).  The  instrument  is  then  closed,  rotated  through 
a  right  angle,  and  the  bone  cut  again  in  a  du'ection  across 
the  first.  The  head  of  the  perforator  can  now  be  slipped 
inside  the  cranial  cavity,  and  the  brain,  including  the  vital 
centres  in  the  medulla,  thoroughly  broken  up.  It  must  be 
remembered  that  the  strong  tentorium  cerebeUi  must  be 
pierced  in  order  to  reach  the  medulla.  By  suprapubic 
pressure  the  greater  part  of  the  cranial  contents  can  now  be 
expressed  ;  or  they  may  be  completely  cleared  out  with  the 
finger  and  a  stream  of  boiled  water  if  desked. 

Perforation  is  an  operation  of  great  simplicity  except  in 
cases  of  non-engagement,  when  the  head  is  so  high  up  as 
to  be  difficult  to  reach  with  the  fingers,  and  accordingly  it 
is  more  difficult  to  keep  the  jDerforator  under  control.  Should 
the  perforator  sUp,  the  uterine  wall  may  be  lacerated  by 
the  pomts,  and  m  some  instances  injury  to  the  sacrum  has 
been  caused  in  this  manner.  When,  after  an  unsuccessful 
attempt  to  deliver  with  forceps,  craniotomy  is  decided  upon, 
the  perforator  should  be  used  before  removing  the  forceps  ; 
this  holds  the  head  very  steady,  and  after  perforation  it  can 
sometimes  be  extracted  with  the  forceps — vide  infra. 

If  the  ojDeration  has  been  performed  upon  the  after- 
coming  head,  traction  on  the  trunli,  combined  with  supra- 
pubic pressure,  wiQ  suffice  for  dehvery  of  the  perforated 
head,  unless  the  degree  of  pelvic  contraction  is  extreme, 
when  crushing  will  be  required.  With  the  fore-coming 
head  extraction  is  more  difficult,  and  a  preliminary  crushing 
is  generally  advisable. 

When  the  amount  of  pelvic  contraction  is  small,  perfora- 
tion and  removal  of  the  cranial  contents  may  reduce  the  size 


PERFORATION  741 

of  the  head  sufficiently  to  allow  it  to  come  through  without 
crushing.  The  child  may  then  be  delivered  by  version  if  the 
local  conditions  are  favourable  for  this  operation,  and  the 
conjugate  measures  at  least  3  inches,  the  pelvis  being 
flattened,  not  generally  contracted.  In  cases  in  which 
perforation  is  performed  after  the  head  has  passed  through 
the  brim,  it  may  be  delivered  with  forceps  if  the  amount  of 
contraction  is  small,  but  this  instrument  must  not  be  used  if 
the  head  is  above  the  brim. 

The  perforated  head  may  be  extracted  with  either  the 
cranioclast  or  the  cephalo tribe — vide  infra.  In  using  the 
former  the  head  is  first  turned  to  a  face  presentation  by  pull- 
ing down  the  chin  with  a  crotchet  hooked  into  the  mouth. 
Then  the  female  blade  is  applied  over  the  face,  the  male  blade 
passed  into  the  perforation  aperture,  or  simply  over  the 
collapsed  vertex.  The  method  of  extraction  with  the  cepha- 
lotribe  is  described  below.  Munro  Kerr  recommends  the 
use  of  the  crotchet  (sharp  hook)  as  an  alternative  to  the 
cephalotribe  ;  this  instrument  may  be  passed  into  the  per- 
foration aperture  and  a  firm  hold  obtained  of  the  irregular 
bones  of  the  base  of  the  skull.  Firm  traction  may  then  be 
applied  to  the  head  to  deliver  it. 

It  is  not  necessary  to  crush  the  after-coming  head  after  it 
has  been  perforated,  unless  the  degree  of  pelvic  contraction 
is  extreme.  By  steady  traction  on  the  trunk,  aided  by 
fundal  pressure,  the  cranial  bones  collapse,  and  the  head 
becomes  narrowed  and  elongated  vertically.  If  difficulty 
is  experienced  the  cephalotribe  may  be  applied, 

(2)  Crushing  and  Extraction. — The  amount  of  crushing 
required  is  determined  by  the  available  pelvic  space.  Two 
degrees  must  be  described  :  •  {a)  simply  crushing  the  skull 
(cephalotripsy)  ;  (b)  removing  the  vault  and  then  crushing 
the  face  (cranioclasm) .  As  extraction  is  performed  with  the 
crushing  instruments,  crushing  and  extraction  may  be  con- 
sidered together. 

(a)  Cephalotripsy. — The  best  form  of  cephalotribe  is  that 
of  Braxton  Hicks  (Fig.  347).  It  is  a  pair  of  very  powerful 
forceps,  the  blades  of  which  are  thick  and  narrow,  with  a 
slight  pelvic  curve.  When  closed  they  are  in  contact  by 
their  incurved  tips  ;  the  maximum  distance  between  them 
does  not  exceed  1|^  inches.     The  handles  are  locked  like  the 


742 


OBSTETRIC   OPERATIONS 


forceps,  and  furnished  with  a  powerful  screw,  by  means  of 
which  the  blades  can  be  forced  together  and  the  head  crushed 
between  them.  The  instrument  is  applied  in  the  transverse 
diameter  of  the  pelvis  in  the  same  manner  as  the  forceps  ; 
when  the  pelvis  is  flattened  this  implies  that  the  head  will 
be  seized  in  the  antero-posterior  diameter,  one  blade  pass- 
ing over  the  face,  the  other 
over  the  occiput.  This  grip 
is  the  most  secure  which  can 
be  obtained  and  the  most 
effective,  inasmuch  as  the 
reduction  in  size  which  it 
produces  is  greater  than 
where  the  head  is  gripped 
in  any  other  diameter.  If 
the  head  is  not  engaged  in 
the  transverse  diameter  of 
the  pelvis  the  grip  of  the  in- 
strument will  be  oblique,  and 
not  only  less  secure,  but  also 
less  effective  in  reducing  the 
size  of  the  head.  In  the 
generally  contracted  pelvis 
the  oblique  engagement  of 
the  head  and  the  relative 
narrowness  of  the  transverse 
diameter  of  the  pelvis  render 
the  use  of  the  cephalotribe 
more  difficult  than  in  a  flat 
pelvis. 

On  account  of  the  nar- 
rowness and  great  weight 
of  the  blades,  it  is  much 
more  difficult  to  prevent 
them  from  slipping,  and 
great  care  must  be  taken  to  direct  each  blade  into  its  proper 
position  and  keep  it  there  with  the  fingers.  When  the  blades 
have  been  applied  and  the  handles  locked,  the  screw  is  ad- 
justed and  crushing  begun.  The  blades  are  now  liable  to 
slip  backwards  off  the  head,  unless  care  is  taken  to  keep  the 
instrument  in  the  axis  of  the  brim  and  retain  the  blades  in 


EiG.  347. — Cephalotribe  of 
Braxton  Hicks. 


CRUSHING 


743 


their  proper  position  in  contact  with  the  head.  The  screw 
should  be  slowly  tightened  until  the  handles  are  nearly  in 
contact,  while  the  internal  fingers  take  note  of  the  position 
of  the  blades.  If  the  amount  of  resistance  encountered  by 
the  screw  is  small,  this  generally  means  that  the  blades  are 
slipping  and  the  head  is  not  being  properly  crushed.  They 
should  then  be  unscrewed  and  re-applied,  care  being  taken  to 
pass  one  of  the  blades  well  over  the  face,  which  usually  gives 
a  secure  grip.  When  the  handles  have  been  well  screwed 
together  the  crushing  is 
completed. 

It  will  be  observed 
that  the  crushed  dia- 
meter of  the  head  now 
lies  in  the  transverse 
of  the  pelvis  ;  delivery 
will  be  facilitated  in  a 
flat  pelvis  if  the  instru- 
ment is  rotated  so  as  to 
bring  the  crushed  dia- 
meter into  the  conju- 
gate where  the  space 
is  limited.  The  amount 
of  pelvic  curve  on  the 
instrument  is  slight,  and 
does  not  contra-indicate 
extraction  in  the  conju- 
gate. 

Extraction.  —  Before 
beginning  the  extrac- 
tion the  perforation 
aperture  must  be  ex- 
amined and  the  edges  of  the  scalp  turned  in  over  the  edges 
of  the  bone,  so  as  to  avoid  laceration  of  the  vaginal  walls 
by  protruding  spicules.  Traction  should  always  be  made 
in  the  axis  of  the  pelvis.  The  cephalotribe  is  a  very  power- 
ful tractor,  and  at  first  great  gentleness  must  be  used  until 
it  is  clear  that  the  grip  is  secure.  If  traction  does  not  cause 
the  head  to  advance,  the  blades  are  probably  slipping.  An 
antiseptic  intra-uterine  douche  should  always  be  given  after 
crushing  operations. 


Fig.  348. — The  Cephalotribe   appHed  to 
the  Head  for  Crushino:. 


744 


OBSTETRIC   OPERATIONS 


The  application  of  the  cephalotribe  to  the  after-coming 
head  needs  no  separate  description. 

A  three-bladed  cephalotribe  has  been  introduced  by 
Winter  and  modified  by  Auvard.  The  middle  blade  is 
first  passed  into  the  perforation  aperture  ;  this  is  held  in 
position  by  an  assistant  while  the  first  outer  blade  is  passed — 


Pia.  349a. — Cranioclast. 


Fig.  349Z). — Cranioclast  applied 
to  the  Face  after  Eemoval 
of  the  Tault  of  the  Skvll. 


preferably  over  the  face.  These  two  blades  are  then  screwed 
up,  thus  crushing  the  anterior  part  of  the  head.  Then  the 
second  outer  blade  is  passed— over  the  occiput,  and  screwed 
up  in  turn  to  the  middle  blade.  The  grip  thus  obtained  is 
very  firm,  and  the  amount  of  reduction  of  the  head  is  greater 
than  that  obtained  by  the  ordinary  cephalotribe. 

(6)  Cranioclasin. — This  operation  consists  in  the  avulsion 


CRANIOCLASM  745 

of  the  bones  of  the  cranial  vault,  followed  by  crushing  the 
remaining  part  of  the  head — i.e.  the  face.  It  is  probably 
never  really  required  unless  the  conjugate  is  reduced  to 
2|  inches  or  less. 

The  cranioclast  or  craniotomy  forceps  consists  of  a  pair  of 
concavo-convex  blades,  the  outer  or  larger  of  which  (Fig. 
349a)  is  fenestrated,  the  smaller  solid  ;    their  apposed  sur- 
faces are  strongly  serrated.     The  instrument  is  powerful  but 
not  so  heavy  as  the  cephalotribe,  and  the  handles  are  closed 
in  the  same  way  by  a  screw.     It  may  be  used  for  traction 
alone,  or  for  breaking  up  the  vault  of  the  skull  (cranioclasm). 
When  used  for  traction  alone,  the  small  blade  is  passed  into 
the  cranial  cavity  through  the  perforation  hole  ;    the  outer 
blade  is  applied  either  over  the  face,  the  occiput,  or  one  or 
other  parietal  bone.     The  handles  are  then  screwed  tightly 
together  and  traction  begun  ;  only  when  the  degree  of  pelvic 
contraction  is  moderate  can  delivery  be  effected  in  this  way. 
When  used  for  breaking  up  the  vault,  the  small  blade  is  passed 
into  the  cranial  cavity,  and  the  large  one  between  the  scalp 
and  the  bone  ;    the  handles  are  then  screwed  up  and  the 
portion  of  bone  gripped  by  the  instrument  is  twisted  off  and 
withdrawn.    The  process  is  repeated  until  the  vault  has  been 
entirely  removed.     Extraction  is  then  performed  by  first 
extending    the    head    by    combined   vaginal    and    external 
manipulations,  so  as  to  produce  a  face  presentation  ;  a  sharp 
hook  is  then  fixed  in  the  jaw  to  steady  the  head,  and  the 
cranioclast  applied  over  the  face,  the  small  blade  being  passed 
into  the  cranial  cavity,  the  large  blade  beneath  the  chin  (Fig. 
3496).      The    bones  of  the  face  are  then  crushed,  and  the 
head,  now  greatly  reduced  in  bulk,  can  easily  be  extracted. 
Instruments  have  been  devised  for  the  purpose  of  breaking 
up  the  base  of  the  skull  after  perforation,  in  cases  of  extreme 
pelvic  contraction  ;   this  procedure  has  been  called  basilysis, 
and  the  instrument  the  hasilyst.    Cases  of  pelvic  deformity  so 
extreme   as   to   require   this   operation   are   almost   always 
recognised  during  pregnancy  or  sufficiently  early  in  labour  to 
permit   of   Csesarean   section   being   performed.     With   the 
progressive  improvement  in  the  standard  of  obstetric  know- 
ledge among  midwives  and  medical  practitioners,  the  neces- 
sity for  the  use  of  such  procedures  as  these  may  be  expected 
to  disappear. 


746 


OBSTETRIC   OPERATIONS 


B.  Decapitation. — This  operation  may  be  required  in 
impacted  transverse  presentations,  in  the  case  of  locked 
t^^ins,  or  with  double-headed  monstrosities.  The  com- 
monest   indication    for    its    performance    is    a    transverse 


Fig.   3o0a. 
Decapitation  Hook. 


Fig.   3oOb. 
How  to  hold  the  Decapitation  Hook. 


presentation  in  which  unsuccessful  attempts  to  dehver  by 
version  have  been  previously  made. 

It  may  be  performed  ^^ith  a  strong  pair  of  curved  scissors, 
but  the  safest  instrument  to  employ  is  the  decapitation  hook 
(Fig.  350a).  The  one  generally  used  in  this  country  is  a 
wide  hook  with-  a  blunt  point  and  either  a  cutting  (Rams- 
botham's  hook)  or  a  serrated  edge.  The  handle  is  sufficiently 
long  for  it  to  be  used  when  the  neck  is  at  the  pelvic  brim.    In 


DECAPITATION 


747 


the  case  of  a  transverse  presentation,  decapitation  may  be 
performed  as  follows  :  If  an  arm  is  prolapsed,  traction  can 
be  made  upon  it  so  as  to  bring  the  neck  down  as  low  as  pos- 
sible. Careful  exploration  with  the  fingers  having  been  made 
to  recognise  the  position  of  the  back  and  the  side  to  which 
the  head  lies,  the  hook  is  introduced  along  the  palm  of 
the  hand  and  guided  upwards  between  the  shoulder  and  the 
anterior  pelvic  wall  (dorso-anterior  positions)  until  the  point 


Fig.   351. — Introduction   of    the  Decapi- 
tation Hook.     (Barnes.) 


lies  above  the  neck.  It  is  then  rotated  through  a  right  angle 
so  as  to  carry  the  cutting  edge  across  the  neck  (Fig.  351)  ; 
the  fingers  are  then  passed  up  the  ventral  aspect  of  the 
foetus  so  as  to  guide  the  point  of  the  hook  into  position  across 
the  neck.  Decapitation  is  performed  by  a  sawing  movement, 
the  fingers  of  the  left  hand  being  kept  in  contact  with  the 
point  of  the  hook  to  protect  the  maternal  passages  from 
injury.  The  soft  foetal  bones  are  easily  divided  in  this 
manner.     After  severing  the  head,  the  trunk  is  delivered 


748  OBSTETRIC   OPERATIONS 

either  by  bringing  down  both  arms  or  by  podahc  version. 
When  the  back  presents,  it  is  sometimes  necessary  to  divide 
the  spinal  column,  in  addition  to  decapitating.  Lastly,  the 
retained  head  may  be  delivered  with  forceps,  if  the  pelvis  is 
of  normal  size,  or  crushed  with  the  cephalotribe,  if  the  pelvis 
is  contracted  ;  perforation  is  unnecessary,  as  the  cranial 
contents  will  escape  through  the  vertebral  canal.  In 
decapitating  the  after-coming  head  a  long,  strong  pair  of 
scissors  will  suffice. 

Decapitation  may  be  performed  in  a  somewhat  different 
manner  by  the  use  of  Braun's  hook  (Fig.  352).  This  instru- 
ment is  blunt,  its  crook  very  narrow  and  ending  in  a  bulbous 
point.  It  is  intended,  not  to  cut  through  the  neck,  but 
merely  to  dislocate  the  cervical  vertebrae.  It  is  passed  over 
the  neck  in  the  manner  already  described,  and  made  to 


Fig.  352. — Braun's  Decapitation  Hook. 

include  the  vertebral  column  ;  the  hook  is  then  forcibly 
rotated,  so  as  to  dislocate  the  vertebrae.  The  soft  tissues  are 
then  divided  with  scissors.  The  advantage  of  this  instrument 
is  its  small  size. 

In  an  impacted  shoulder  presentation  the  cord  and  an 
arm  are  usually  prolapsed,  and  by  the  time  the  body  of  the 
child  has  become  impacted  it  has  ceased  to  live.  Even  if 
feeble  pulsation  in  the  cord  can  still  be  felt,  there  is  no 
possibility  of  delivering  rapidly  enough  to  save  its  life  ; 
consequently  delivery  may  be  conducted  solely  in  the 
interests  of  the  mother.  If  the  uterus  is  retracted,  the  lower 
segment  distended  and  Bandl's  ring  palpable,  decapitation 
is  clearly  indicated,  for  version  would  be  attended  with  the 
gravest  risks  of  rupture.  If  the  conditions  are  not  quite  so 
unfavourable  as  this,  the  uterus  may  become  sufficiently 
relaxed  under  surgical  anaesthesia  to  allow  of  version  being 


SYMPHYSIOTOMY  749 

performed,  but  no  unnecessary  risk  should  be  run  if  the  child 
is  dead. 

When  the  lower  segment  is  markedly  distended,  even 
decapitation  is  attended  by  a  certain  risk  of  rupture  from  the 
introduction  of  the  fingers  and  the  hook.  Great  care  must  be 
exercised,  and  if  difficulty  is  encountered,  decapitation  should 
be  abandoned  in  favour  of  evisceration. 

C.  Evisceration. — This  operation  consists  in  opening  the 
abdomen  or  thorax  with  strong  scissors  in  the  most  accessible 
position,  and  removing  the  abdominal  and  thoracic  viscera 
piecemeal  with  the  fingers.  It  may  also  be  necessary  to 
divide  the  spinal  column  before  the  trunk  can  be  delivered. 
It  is  indicated  in  transverse  presentation  as  an  alternative  to 
decapitation,  and  in  cases  of  obstruction  from  abdominal  or 
thoracic  enlargement  (ascites,  cystic  disease  of  kidneys,  &c.). 

D.  Cleidotomy. — This  operation  consists  in  dividing  one 
or  both  clavicles  with  a  strong  pair  of  scissors.  Division  of 
the  clavicles  is  sometimes  required  when,  owing  to  the  large 
size  of  the  trunk  or  the  narrowness  of  the  pelvic  outlet,  the 
shoulders  cannot  be  extracted  and  the  child  is  dead. 

Symphysiotomy  ;  Pubiotomy. 

Symphysiotomy  consists  in  dividing  the  symphysis  pubis 
so  as  to  produce  a  temporary  enlargement  of  the  pelvis 
sufficient  to  permit  the  delivery  of  a  living  child  by  the  natural 
passages.  Though  sometimes  performed  upon  the  dead 
woman  during  the  sixteenth  and  seventeenth  centuries,  it  was 
not  performed  upon  the  living  woman  until  1774.  Owing 
to  the  terribly  high  mortality  of  Csesarean  section  at  this 
period,  symphysiotomy  was  at  first  frequently  performed ; 
but  it  soon  fell  into  disrepute  and  was  practically  abandoned, 
as  the  results  were  no  better  than  those  of  Csesarean  section. 
More  recently  it  has  again  been  advocated  by  Morisani  of 
Naples,  and  Pinard  of  Paris,  but  is  not  generally  regarded 
with  favour  owing  to  the  extremely  limited  scope  of  its 
application,  and  the  comparatively  unfavourable  results 
which  it  still  shows. 

The  effects  of  division  of  the  symphysis  upon  the  pelvic 
diameters  are  not  entirely  clear.  When,  in  the  cadaver,  the 
pubic  bones  are  separated,  a  considerable  amount  of  strain 


750  OBSTETRIC   OPERATIONS 

is  placed  upon  the  anterior  Kgaments  of  the  sacro-ihac  sjai- 
chondroses,  and  these  structures  may  suffer  serious  injurj^  ; 
in  addition,  rotation  of  the  innominate  bones  round  a  trans- 
verse axis  passing  through  these  joints  occurs,  which  carries 
the  pubes  doT\Ti wards  as  in  Walcher's  position  (Fig.  334)  ; 
lastly,  a  sHght  movement  of  rotation  of  each  innominate  bone 
round  its  own  long  axis  occurs,  which  shghtly  increases  the 
distance  between  the  ischial  tuberosities  (Sandstein).  The 
pubic  bones  must  not  be  allowed  to  separate  for  more  than 
2^  inches  (Budin  and  Demehn),  or  rupture  of  the  sacro-ihac 
ligaments  vnU.  occur.  This  degree  of  separation  increases 
the  conjugate  of  the  pelvic  brim  by  about  one-third  of  an 
inch,  the  increase  being  relatively  rather  greater  in  a  markedly 
contracted  pelvis  than  in  one  only  slightly  contracted.  The 
obhque  diameters  of  the  brim  are  increased  about  twice  as 
much,  and  the  transverse  about  three  times  as  much,  as  the 
conjugate.  The  marked  increase  obtained  in  the  transverse 
diameter  is,  however,  of  httle  use  without  a  corresponding 
increase  in  the  conjugate.  The  amount  of  increase  obtained 
at  the  outlet  is  probably  very  small. 

Indications. — It  is  obvious  from  the  above  that  symphy- 
siotomy can  only  be  apphcable  to  cases  of  shght  disparity 
between  the  size  of  the  foetal  head  and  that  of  the  pelvis. 
The  degree  of  disparity  in  any  given  case  is  by  no  means 
easy  to  estimate  exactly,  and  as  precise  measurement  of  the 
foetal  head  in  labour  is  impracticable,  the  indication  for  the 
operation  has  to  be  based  mainly  upon  the  length  of  the  pelvic 
diameters.  There  is  therefore  abundant  room  for  error. 
Unless  the  conjugate  of  the  brim  is  at  least  3  inches  in  length 
there  is  very  httle  prospect  of  success  ;  in  pelves  of  greater 
size  than  this  the  prospect  of  success  is  better.  With  these 
reservations,  symphysiotomy  may  be  performed  when  the 
head  is  delayed  at  the  brim  in  a  flat  or  generally  contracted 
pelvis,  or  at  the  outlet  in  a  fmmel  pelvis,  the  degree  of 
disparity  between  the  pelvis  and  the  foetal  head  being  small. 
It  may  be  preferred  to  Caesarean  section  in  cases  of  this  kind 
when  labour  is  advanced,  and  repeated  attempts  to  deliver 
by  other  means  have  already  been  made.  But  if  the  passages 
have  become  infected  during  labour,  symphysiotomy  is 
attended  by  grave  risks  of  septic  infection  of  the  wound  ;  and 
although  this  does  not  communicate  with  the  genital  canal. 


SYMPHYSIOTOMY  751 

serious  and  even  fatal  results  may  follow  from  the  spread  of 
the  infection  to  the  pelvic  cellular  tissue  and  the  vesical 
venous  plexuses. 

If  the  foetus  presents  by  the  breech,  it  is  impossible  to 
estimate  the  relative  sizes  of  head  and  pelvis  until  the  body  is 
born,  when  there  is  no  time  to  perform  symphysiotomy  ; 
therefore  the  operation  is  only  of  use  in  head  presentations. 
If  the  foetus  is  dead,  craniotomy  should  always  be  preferred. 

The  Operation. — Preliminaries. — The  time  for  perform- 
ance of  the  operation  is  at  the  end  of  the  first  or  early  in 
the  second  stage  of  labour  ;  if  necessary,  dilatation  may  be 
hastened  by  de  Ribes's  bag.  The  operator  must,  of 
course,  satisfy  himself  that  the  child  is  ahve.  The  pubes 
should  be  shaved  and  the  abdominal  wall  and  vulva  dis- 
infected. The  operator  requires  three  assistants,  two  of 
whom  will  support  the  thighs  of  the  patient,  who  should  be 
placed  in  the  dorsal  position,  with  the  buttocks  over  the 
edge  of  the  bed  or  operating  table. 

The  operation  may  be  performed  by  the  open  or  the 
subcutaneous  method. 

Open  Method. — (1)  An  incision  2  or  3  inches  long  is  made 
in  the  middle  line  from  a  point  just  above  the  pubes  to  the 
lower  border  of  the  symphysis,  avoiding  the  clitoris  ;  this 
incision  passes  down  to  the  bone,  and  in  its  upper  part 
exposes  the  aponeurosis.  By  blunt  dissection  the  clitoris 
is  pushed  downwards,  and  its  suspensory  ligament  then 
separated  from  the  pubes  by  cutting  through  it  with  scissors  ; 
vessels  divided  at  this  stage  must  be  carefully  secured.  The 
index  finger  is  next  passed  behind  the  symphysis,  and  worked 
downwards  in  the  cellular  tissue  until  the  lower  border  is 
reached  ;  when  the  head  is  engaged  in  a  narrow  brim,  this 
may  be  rather  difficult.  (2)  The  assistant  passes  a  sound 
into  the  urethra  so  that  its  position  may  be  readily  located, 
and  the  operator  divides  the  fibro-cartilage  of  the  symphysis 
with  a  probe-pointed  knife  from  above  downwards.  Some- 
times the  joint  is  not  precisely  in  the  middle  fine,  and  it  will 
be  necessary  to  explore  to  either  side  in  order  to  find  it. 
In  cutting  the  lower  part  of  the  joint  it  is  better  to  inchne 
the  knife  to  one  or  other  side,  so  as  not  to  injure  the  urethra. 
After  the  fibro-cartilage  has  been  divided  the  bones  are  still 
held  together  by  a  gtrong  band  of  fibrous  tissue,  the  sub-pubic 


752  OBSTETRIC   OPERATIONS 

ligament,  which  runs  across  the  pubic  arch  immediately 
below  the  joint.  This  ligament  must  now  be  divided  with 
care,  for  immediately  beneath  it  lies  the  terminal  branch  of 
the  internal  pudic  artery.  (3)  The  pubic  bones  now  separate 
spontaneously,  and  the  two  assistants  in  charge  of  the  legs 
abduct  the  flexed  thighs  gently  until  the  required  amount  of 
separation  is  obtained  ;  this  must  be  measured,  not  guessed. 
The  wound  is  then  plugged  with  antiseptic  gauze  and  the 
legs  held  perfectly  steady  during  the  remainder  of  the  opera- 
tion. (4)  This  consists  in  the  delivery  of  the  child,  which  is 
best  done  with  forceps  ;  great  care  must  be  exercised,  for 
if  much  force  is  exerted  serious  injury  will  be  done  to  the 
pelvic  joints  and  the  urethra.  If  the  placenta  is  delayed, 
it  is  better  to  remove  it  by  the  digital  method.  (5)  The 
wound  is  then  closed  with  four  or  five  deep  silkworm-gut 
sutures,  and  an  antiseptic  dressing  applied.  It  is  unneces- 
sary to  suture  the  bones,  but  a  tight  pelvic  binder  is  applied 
in  such  a  position  as  to  immobilise  the  innominate  bones  and 
thighs.  Some  operators  advise  that  the  vagina  should  be 
plugged  with  antiseptic  gauze.  A  catheter  should  be  passed 
immediately  after  the  operation  to  make  sure  that  the 
urethra  has  not  been  injured  :  if  laceration  has  occurred 
a  soft  rubber  catheter  should  be  tied  in  for  forty-eight  hours. 

Subcutaneous  Method. — A  small  incision  down  to  the  bone 
is  first  made  with  a  tenotomy  knife  in  the  middle  line  just 
below  the  clitoris,  which  should  be  pulled  upwards  as  much 
as  possible.  A  curved  probe-pointed  bistoury  is  then  inserted 
under  the  soft  tissues  and  passed  upwards  nearly  to  the 
upper  border  of  the  symphysis,  cutting  into  the  front  of  the 
cartilage.  The  index  finger  of  the  left  hand  is  then  passed 
into  the  vagina  and  carried  upwards  until  the  blunt  point 
of  the  knife  is  felt  above  the  symphysis.  The  division  of  the 
cartilage  is  then  made  from  above  downwards,  the  resulting 
separation  of  the  bones  being  observed  by  the  finger  in  the 
vagina.  A  sound  should  be  passed  into  the  bladder  and 
the  urethra  displaced  as  much  as  possible  to  one  side  during 
the  operation.  The  child  is  then  delivered,  and  the  operation 
completed  by  the  application  of  an  antiseptic  dressing  and  a 
pelvic  binder. 

Although  symphysiotomy  is  an  easy  and  simple  opera- 
tion, its  results  are  disappointing,  for  the  following  reasons  : 


PUBIOTOMY  753 

(1)  injury  to  bladder  and  urethra  often  occurs  ;,  (2)  the  space 
behind  the  pubic  bones  {cavum  Retzii)  is  difficult  to  drain, 
and  when  accumulations  of  fluid  occur  there  they  easily 
become  infected  ;  (3)  after  the  operation  has  been  success- 
fully performed  it  may  prove  impossible  to  deliver  the  child 
except  by  craniotomy  ;  this  is  explained  by  the  difficulty  of 
estimating  the  degree  of  disparity  between  the  head  and  the 
pelvis. 

Prognosis. — Statistics  of  this  operation,  compiled  by 
Munro  Kerr  from  275  cases  by  well-known  operators,  show 
a  maternal  mortahty  of  6*5  per  cent,  and  a  foetal  mor- 
tality of  10  per  cent.  That  is  to  say,  the  mortality  is  greater 
both  as  regards  the  mother  and  the  child  than  that  of  un- 
complicated Csesarean  section.  The  complications  most 
likely  to  be  met  with  are  injuries  to  the  urethra  or  bladder, 
and  septic  infection  of  the  operation  wound.  Firm  union 
of  the  symphysis  almost  always  occurs,  but  some  cases  of 
temporary  and  some  even  of  permanent  lameness  have  been 
reported. 

Pubiotomy  :  Hebotomy.  —  This  operation  resembles 
symphysiotomy  in  its  general  features,  and  the  indications 
for  its  performance  are  the  same.  Instead  of  dividing  the 
symphysis  pubis,  the  body  of  the  pubic  bone  is  divided  about 
J  to  f  of  an  inch  to  one  or  other  side  of  the  joint.  It  is 
claimed  that  this  operation  allows  of  greater  increase  in 
the  diameters  of  the  brim  than  symphysiotomy,  and  further 
that  the  pelvis  is  permanently  enlarged  by  it.  Whitridge 
Williams  has  shown  that  the  effect  of  pubiotomy  upon  the 
diameters  of  the  outlet  is  well  marked  also,  and  that  the 
operation  is  therefore  serviceable  in  the  funnel  pelvis. 
He  observed  a  permanent  increase  in  the  transverse  diameter 
of  the  outlet  of  from  1  to  3  cm.  in  funnel  pelves  which  had 
been  subjected  to  this  operation.  It  is  also  claimed  that 
there  is  not  the  same  risk  of  injuring  the  urethra. 

Pubiotomy  may  be  performed  by  the  open  or  the  sub- 
cutaneous method.  In  the  open  method  a  vertical  incision  is 
made  just  internal  to  the  pubic  spine  (to  avoid  the  external 
inguinal  ring),  and  about  3  inches  in  extent.  It  may  be 
made  upon  either  side,  and  is  carried  down  to  the  anterior 
surface  of  the  bone.  Next  the  rectus  sheath  is  divided  and 
the  finger  is  passed  down  behind  the  pubic  bone  to  the  lower 
E.M.  48 


754  OBSTETRIC    OPERATIONiS 

border  of  thf  pubic  arch.  A  curved  metal  hook  or  carrier 
is  then  entered  above,  directed  behind  the  bone  by  the  finger, 
and  brought  out  below  it  in  front.  With  the  aid  of  the 
carrier  a  Gigli's  saw  is  passed  and  the  bone  divided.  Formi- 
dable hsemorrhage  may  occur  from  the  subcutaneous  tissues 
and  from  the  pelvic  cellular  tissue,  and  from  the  corpus 
cavemosum  which  is  necessarily  injured  by  the  saw. 

In  the  subcutaneous  method  a  small  incision,  about  an  inch 
in  length,  is  made  just  above  and  internal  to  the  pubic  spine, 
and  a  special  curved  pubiotomy  needle  is  passed  behind  the 
bone  and  made  to  emerge  below  the  pubic  arch  by  piercing 
the  soft  tissues  in  that  position.  Through  the  needle  a  piece 
of  stout  silk  is  threaded,  with  which  GigH's  saw  is  drawn  up 
behind  the  bone,  and  brought  out  at  the  supra-pubic 
incision. 

The  late  results  of  pubiotomy  are  not  unfavourable.  The 
bones  reunite  by  fibrous  union  only,  but  this  does  not 
interfere  "with  locomotion,  and  a  certain  amount  of  perma- 
nent increase  in  the  pelvic  diameter  has  been  repeatedly 
observed. 

The  operations  of  symphysiotomy  and  pubiotomy  have 
not  been  extensively  adopted  in  this  country,  although 
several  short  series  of  cases  have  been  recorded  by  British 
operators.  Conditions  in  which  they  are  indicated  can  also 
be  dealt  with  by  Csesarean  section,  and  this  operation  is 
usually  preferred  for  the  reasons  already  stated. 

Both  operations  are  more  formidable  than  Csesarean 
section,  and  it  has  still  to  be  shown  whether  they  possess  any 
compensating  advantages. 

Primary  Repair  of  the  Perineum 

All  obstetric  lacerations  of  the  perineum  exceeding  J  inch 
in  depth  should  be  repaired  immediately.  Such  lacerations 
heal  well  if  repaired  at  any  time  within  forty-eight  hours 
after  dehvery.  Primary  union  can  be  obtained  if  surgical 
cleanliness  is  observed  ;  but  when  lacerations  are  allowed 
to  remain  unsutured  they  frequently  become  infected  during 
the  puerperium,  and  may  later  on  lead  to  the  occurrence 
of  prolapse  or  rectal  incontinence. 

Three  types  of  laceration  may  be  described.     In  th.Q  first y 


PERINEAL  LACERATIONS 


755 


which  is  usually  overlooked,  the  laceration  at  first  sight 
appears  to  involve  only  the  anterior  edge  of  the  perineal 
body  ;  if,  however,  the  vulva  is  held  open  with  the  fingers 
it  will  be  seen  that  a  comparatively  deep  laceration  runs 
upwards  and  somewhat  outwards  into  the  vaginal  wall  on 
one  or  both  sides  (Fig.  353,  a).     If  this  apparently  trivial 


.^ 


Fig.  353. — Perineal  Laceration  :  a.  First  Type.     I.  Second  Tyiae. 

(Edgar.) 

tear  is  neglected,  it  may  lead  subsequently  to  the  condition  of 
relaxed  vaginal  outlet  and  prolapse  of  the  vaginal  walls,  for 
it  is  frequently  deep  enough  to  affect  the  posterior  fibres  of 
the  levator  ani  and  the  anal  fascia,  which  support  the 
posterior  vaginal  wall.  It  should  be  repaired  with  inter- 
rupted catgut  stitches,  as  shown  in  the  figure. 

In  the  second  type  the  laceration  involves  the  greater  part 
of  the  perineal  body  and  a  considerable  part  of  the  posterior 

48—2 


756  OBSTETRIC   OPERATIONS 

vaginal  wall,  but  the  anus  and  its  sphincter  escape.  This 
type  is  sufficiently  obvious  to  be  generally  recognised  and 
sewed  up.  It  is  best  repaired  by  a  series  of  sutures  intro- 
duced, some  through  the  perineum  and  some  through  the 
posterior  vaginal  wall  (Eig.  353,  h)  ;    this  is  preferable  to 


Fig.  354. — ^Perineal  Laceration  :  Thii-d 
Type.     (Edgar.) 

Xote  that  tlie  skin  suture  lias  passed  through  the  torn 
ends  of  the  sphincter  aui  muscle. 

passing  them  all  through  the  perineal  surface  and  endeavour- 
ing to  include  the  upper  end  of  the  vaginal  rent,  for  accurate 
apposition  of  the  edges  of  the  vaginal  mucous  membrane, 
so  necessary  for  a  good  result,  cannot  be  obtained  in  this 
way.     Strong  catgut  is  the  best  suture  material. 

In  the  third  type,  posterior  vaginal  waU,  permeal  body, 
and  anus  are  all  torn  through,  establishing  direct  communi- 


PERINEAL   LACERATIONS  757 

cation  between  the  vagina  and  rectum  (Fig.  354).  This 
severe  laceration  requires  very  careful  treatment,  or  the 
patient  will  suffer  from  incontinence  of  fseces.  The  edges  of 
the  rectal  mucous  membrane  are  first  carefully  united  by  a 
series  of  interrupted  catgut  stitches,  which  must  be  tied  on 
the  rectal  side.  Then  the  torn  edges  of  the  posterior  vaginal 
wall  are  united  in  the  same  manner  ;  and  lastly  deep 
sutures  of  sill^worm-gut  are  passed  through  the  perineal 
surface,  the  lowest  of  which  should  include  the  divided  and 
retracted  ends  of  the  sphincter  ani  muscle. 

When  the  delivery  has  occurred  with  the  patient  under 
the  influence  of  chloroform,  perineal  sutures  may  usually  be 
introduced  immediately,  before  the  anaesthesia  passes  off, 
without  waiting  for  the  expulsion  of  the  after-birth.  The 
sutures  should  be  clamped  in  position  by  artery  forceps  and 
only  knotted  when  the  after-birth  has  been  delivered  ;  other- 
wise, if  digital  removal  of  the  placenta  should  become 
necessary,  the  operation  would  have  to  be  repeated.  This 
obviates  the  necessity  of  giving  more  chloroform  in  order  to 
pass  the  sutures  when  the  third  stage  is  over.  In  severe 
lacerations  involving  the  rectum,  it  is  better  to  wait  until 
after  the  delivery  of  the  placenta  before  beginning  the 
operation,  as  considerable  time  is  required  in  passing  the 
sutures. 

The  patient  should  be  placed  in  the  lithotomy  position, 
and  the  parts  well  exposed,  for  accurate  suturing  is  essential. 
Although  considerably  bruised  and  torn,  the  parts  heal  well 
if  properly  adjusted  with  stitches. 


INDEX 


Abderhalden's   test   in   pregnancy, 

81,  112 
Abdomen,  examination  of,  87 
incision  of,  726,  732 
massage  of,  558 

of  pregnant  woman  at  term,  312 
pendulous,  140,  409 
pigmentary  changes  of,  75 
Abdominal  manipulation   of   uterus, 
521 
palpation,  312,  378 
pregnancy,  secondary,  194 
wall,  sterilisation  of,  726 
Abortifacients,  220 
Abortion,  218 

after-treatment  of,  236 
anatomy  of,  227 

ovum     almost     completely 

detached,  223 
ovum  partially  detached,  222 
six  weeks'  ovum,  227 
two  and  a  half  months,  229 
two  to  three  weeks,  226 
causation  of,  219 
clinical  features  of,  221 
criminal,  652 

differential  diagnosis  of,  229 
drugs  useful  in,  231 
frequency  of,  221 
incomplete,  226 
induction  of,  131 

during  first  three  months  of 

pregnancy,  653 
during  second  three  months 

of  pregnancy,  655 
indications,  651 
Krause's  method,  661,  663 
methods,  653 
rapid  method,  655 
slow  methods,  658,  660,  670 
inevitable,  225 

treatment  of,  231 
missed,  226 
nephritis  causing,  207 
pathological  conditions   causing, 

219 
prevention  of,  230 
septic,  236 
stages  of,  222 
syphilis  causing,  202 
threatened,  223 

treatment  of,  231 


Abortion —  contd. 

treatment  of,  230 
tubal  pregnancy  terminating  in, 
174,  177 
Abscess,  mammary,  603 
Accouchement /orce,  736 
in  eclampsia,  539 
in  induction  of  abortion,  670 
Acidosis,  110,  130 
Adhesions,  amniotic,  161 
After-birth,  delivery  of,  253 
After-pains  in  the  puerperium,  555 
After-treatment  of  Caesarean  section, 

734 
Age,  factor  in  labour,  241 

in  pregnancy,  83 
Albuminuria  and  eclampsia,  113 
during  pregnancy,  113,  206 
clinical  features,  114 
etiology,  120 
treatment,  124 
Alimentary   canal,    treatment   of   in 

eclampsia,  534 
AUantois,  51 

Amenorrhoea,  symptomatic,  84,  185 
Amino-acids,  82 
Amnion,  47 

formation  of,  13 
Amniotic  adhesions,  161 

vesicle,  20 
Anaemia  and  anasarca,  clinical  features 

of  albuminuria,  115 
Anaesthetics,    chloroform  weU  borne, 
726 
in  convulsions  of  eclampsia,  536 
in  second  stage  of  labour,  327, 
329 
Anasarca  in  albuminuria,  115,  142 
Anatomy  and  physiology  of  first  and 
second  stages  of  labour,  254 
of  third  stage  of  labour,  279 
pathological,     of   puerperal    in- 
fection, 571 
Ante-partum  rupture  of  membranes 

in  abnormal  labour,  453 
Anti-bodies,  590 
Antiseptics  in  management  of  normal 

labour,  308 
Anuria  in  eclampsia,  535 
Appendicitis,  in  pregnancy,  213 
Arm,  paralysis  of,  645 
prolapse  of,  393 


760 


INDEX 


Arms,  delivery  of,  difficulty  in  breech 

presentations,  374 
Arterial  tension  in  pregnancy,  76 
Arteries,  foetal,  60 
Artificial  feeding,  621 

respiration,  methods  of,  636 
Ascites,  foetal,  460 
Asepsis  in  the  puerperium,  556 
Aseptic  precautions,  310 
Asphyxia,  blue  or  cyanotic,  634 

neonatorum,  633 

palUd  or  white  form,  634 

treatment  of,  635 
Ass's  milk,  composition  of,  621 
AsyncHtism,  anterior,  289,  290 

posterior,  291 
Attitude,  foetal,  286 

deficient  flexion  of  head,  267 

normal,  265,  268 
Auscultation     in     abnormal    labour, 
347 

of  foetal  heart,  318 
Autogenetic  infection,  567 
Axis  of  internal  os,  285 

pelvic,  256,  260 
Axis-traction  forceps,  application  of, 
703,  705 

applied  to  head,  694 

delivery  by,  710 

extraction  of  head,  709 

introduction  of  blades,  706,  708 

locking  of  blades,  707 

Murray's,  693 

NeviUe's,  697 

traction  with,  709,  712 

Walcher's  position,  711,  713 

when  pelvis  is  contracted,  712 

with  head  in  lower  part  of  cavity, 
705 

with  head  in  upper  part  of  cavity, 
711 

Bacilli,    specific,   in    puerperal    in- 
fection, 566 
Bacillus    coh    infection,   acute,    and 
pregnancy,  208 

causation  of,  in  pregnancy,  209 

chronic  and  pregnancy,  208 

diagnosis  of,  210 

mode  of  infection,  209 

pregnancy  and,  207 

treatment,  210 
Bacteria  of  puerperal  infection,  564 
Bacteria,  anserobic,  564 

pyogenic,  565 

saprophytic,  564 

specific    organisms    in  puerperal 
infection,  566 
Bacterial  infection  of  eclampsia,  124 
Bag  of  waters,  during  a  pain,  323 

formation  of,  246 
Ballottement,  external,  92 
internal,  90 


Bandl's  ring,  275 

Barne's  ring,  275 

Basilysis,  745 

Battledore  placenta,  163,  164 

Bicornate   uterus   with   rudimentary 

horn,  142 
Biniodide  of  mercury,  311 
Bi-polar  or  combined  version,  687 

version,  preUminaries  and  steps 
in,  687 
Birth  paralysis,  644 
Bladder,  disordered  function  of,  135 
irritability  of,  symptom  of  preg- 
nancy, 86 
separation  of,  from  front  of  cervix, 
234  . 
Blastodermic  vesicle  or  blastocyst,  12 
Blood,  circulation  through  placenta, 
40 
deficient  coagulabihty  of,  519 
disorders  of  in  pregnancy,  110 
during  pregnancy,  76,  81 
in  the  puerperium,  546 
in  septicaemia,  583 
foetal,  character  of,  58 
Blood-mole,  143 

Blood  pressure  in  pregnancy,  76 
Blood-vessels,  foetal,  58 
placental,  40 

uterine,  involution  changes,  553 
Body-weight  in  the  puerperium,  548 
Bone,    right    frontal,     spoon-shaped 

indentation  of,  643 
Bones   of   head,   depression   and   de- 
pressed fractures  of,  642 
pelvic,  tumours  of,  432 
Bougies,  intra-uterine,  for  induction 
of  abortion,  661 
sterihsed,  case  for,  662 
Brain,    morbid    appearances    of,    in 

eclampsia,  119 
Braun's  decapitation  hook,  748 
Breast,  putting  child  to,  617 
Breastfeeding,  contra-indications  for, 
617 
of  the  new-born  child,  617 
Breasts,  care  of,  during  suckUng,  561 
enlargement     of,     symptom     of 
pregnancy,  86 
Breech  hook,  373 
Breech  or  pelvic  presentation,  672 
Breech  presentation,  bringing  down  a 
leg  in,  372 
causes,  359 
diagnosis,  361 
difficulties  in,  371 
external  version  in,  672 
in  abnormal  labour,  358 
in  flat  pelvis,  412 
in  twin  labour,  386 
management  of,  367 
mechanism  of,  362 
anomalies,  366 


INDEX 


761 


Breech  presentation — contd. 

occurrence,  359 

positions  of,  360 

Ijrognosis  of,  366 
Bregma,  270 
Brim,  pelvic,  255,  261 
Broad  ligament  phlegmn,  574,  595 
Brow  presentations,  344 

diagnosis  of,  356 

in  abnormal  labour,  356 

mechanism  of,  350 
Bryce-Teacher  ovum,  16 
Buttocks,  delivery  of,  371 

CESAREAN  hysterectomy, 

prognosis  of,  736 

supra-vaginal  amputation,  735 

vaginal  Csesarean  section,  735 
Csesarean    section,    absolute    indica- 
tions, 722 

after-treatment  of,  734 

conservative,  720 

craniotomy  alternative  to,  721 

extraction  of  child,  727 

extra-peritoneal,  721,  736 

haemorrhage  in,  729 

historical  retrospect,  719 

in  concealed  haemorrhage,  509 

in  eclampsia,  540 

indications  for,  721,  723 

maternal    complications    indica- 
ting, 723 

mortahty  of,  736 

operative  procedures,  726,  732 

relative  indications,  723 

removal  of  uterus  after,  724 

rupture  of  uterus  through  scar, 
467 

sterilisation  of  patient  after,  734 

survival  of  child,  721 

sutures  in,  730 

treatment  of  placenta  prsevia,  507 

treatment  of  uterus  in,  732 

vaginal,  668,  720,  735 
Cancer  of  cervix  in  abnormal  labour, 
437 

uterine,  217 
Caput,  location  of,  307 

position  of,  616 

succedaneum,  348,  353 

vertex  positions  of,  in  nor- 
mal labour,  306 
Carbohydrate  metabolism,  109 
Carcinoma  syncytiale,  607 
Carneous  mole,  143 
Catgut  sutures,  732 
Cell,  process  of  multiplication,  11 
Cellulitis,  pelvic,  595 

and  puerperal  infection,  574 
Cephalhaematoma,  641 
Cephalotribe,  application  of,  743 

Braxton  Hicks,  741 

three-bladed,  744 


Cephalotripsy,  741 

Cervical    wall,    anterior,    transverse 

laceration  of,  440 
Cervix,  cancer  of,  in  abnormal  labour, 
437 
changes  in,  69 

condition  at  onset  of  labour,  244 
condition  during  a  pain,  323 
condition  in  labour,  274 
digital  dilatation  of,  in  induction 

of  abortion,  668 
dilatation  of,  233,  277 

by  de  Ribes'  bag,  504 
inducing  abortion  by,  653 
dilated,  prolapse  of  cord  with,  392 
erosion  of,  87 
incision  of,  in  rapid  method  of 

abortion,  656 
injuries  to,  by  forceps,  718 
lacerations  of,  478 

and  puerperal  infection,  574 
of  multipara  at  term,  244 

who  died  of  eclampsia,  245 
plugging  of,  506 

rigidity  of,  in  abnormal  labour, 
438 
functional,  438 
organic,  439 
rupture  of  uterus  involving,  470 
Chamberlen's  forceps,   different  pat- 
terns of,  689 
Chick,  amnion  in  development  of;  13 
Child,  growth  of,  620 
progress  of,  620 
survival  of,  chances  in  Csesarean 

section,  721 
See  also  Foetus  and  Newborn. 
Chloral,  administration  of,  537 
Chloroform,  administration  of,  risks 
of,  538 
during  second  stage,  327,  329 
well  borne  in  pregnancy,  726 
Chorea,  pregnancy  and,  212 
Chorio-decidual  space,  30 
Chorion,  changes  in,  35 
formation  of,  13,  31 
frondosum,  40,  49 
hydatidiform     degeneration     of, 

148,  151 
Iseve,  41,  49 
left  in  uterus,  513 
placental,  27 

with  extensive  haemorrhage 
and  vesicular  degeneration 
of,  151 
relations  of,  to  decidua,  27 
vim  of,  33 
Chorionepithelioma,  607 
clinical  diagnosis,  611 
in  puerperium,  607 
microscopical  characters,  607 
treatment,  611 
Chorionic  toxaemia,  112 


762 


INDEX 


Chorionic   villi  from   a    tubal   mole, 
176 
recognition  of,  178 
Chromosomes,  11 
Circulation,  eclampsia  and,  538 
foetal,  58 

changes  in,  at  birth,  60 
maternal,  development  of,  40 
Circulatory  system,  76 

diseases  of  pregnancy  and,  203 
Citrate  of  sodium,  value  of,  624 
Cleidotomy,  749 

Coition,  relation  to  fertilisation,  242 
Colles's  law  of  immunity,  201 
Colostrum,  560 
Colpotomy,  posterior,  197 
Conception,  prevention  after  Csesarean 

section,  734 
Conia,  causes  of,  529 
Conjugate     diameter,     external,     of 

pelvis,  402 
Conjugates,  description  of,  257 
Contraction,  pelvic,  394,  400,  409 
operations  in,  722,  738 
rare  forms  of,  423 
ring,  uterine,  275 
uterine,  70,  243 
Convulsions  in  eclampsia,  anaesthetic 
or  sedative  drugs  for,  536 
character  of,  528 
diagnosis  of,  529 
statistics  of,  527 

treatment  of  toxic  symptoms  in, 
536 
Cord,  umbilical,  51 
at  term,  51 
division  of,  615 
epithelium  of,  53 
insertions  in  placenta,  54,  163 
near  foetal  end,  50 
necrosis  of,  621 

presentation  of,  treated  by  pos- 
ture, 390 
prolapse  of,  in  abnormal  labour, 
causes,  389 
diagnosis,  390 
instrumental,    management, 

390 
presentation,  390 
risks,  390 
twin,  99,  389 
with  true  knot,  52 
Corona  radiata,  3 
Corpus  albicans,  6 
Corpus  fibrosum,  6 
Corpus  luteum,  4,  6 

three  weeks  after  menstruation,  5 
Cow's  milk,  composition  of,  621,  624 
modification  of,  623 
sterilisation  of,  623 
Cramp  in  legs,  142 
Cranioclasm,  method  of,  745 
Cranioclast,  application  of,  744 


Craniotomy,  alternative  to  Csesarean 
section,  721 

indications  for,  737 

perforation  in,  738,  740 
Cream,  value  of,  624 
Crede's  method,  615 
Crile's  shockless  method,  723 
Criminal  abortion,  652 
Crotchet  alternative  to  cephalotribe, 

741 
Curettage  of  uterus,  235 
Curette,  blunt,  588 
Cutaneous  system,  changes  in,  74 
Cystitis  in  the  puerperium,  597 
Cyto-trophoblast,  19 

Dead  tissue,  as  channel  of  infection  in 
puerperal  infection,  569 

Death,  sudden,  in    the    puerperium, 
613 

Decapitation,  737 

hooks,  741,  746,  748 
methods  of,  747 

Decidua  basalis  or  serotina,  22 
capsularis  or  reflexa,  23 
discharge  of,  in  tubal  pregnancy, 

187 
relations  of  chorion  to,  29 
vera,  22,  24 

Decidual  ceUs,  187 
endometritis,  157 
space,  42,  66 

Deciduoma  mahgnum,  607 

DeUvery  by  axis-traction  forceps,  705, 
710 
spontaneous,  in  contracted  pelvis, 
410 

De  Ribes'  forceps,  665 
hydrostatic  bag,  664 

Dessaignes-Ribemont  insufflator,  640 

Diabetes,  pregnancy  and,  211 

Diagnosis  of   bacillus   coli  infection, 
210 
of  breech  presentation,  361 
of  brow  presentation,  356 
of  chorionepitheKoma,  611 
of  contracted  pelvis,  400 
of  convulsions  in  eclampsia,  529 
of  face  presentation,  347 
of  hydatidiform  mole,  156 
of  inversion  of  uterus,  481 
of  labour,  312,  338 
of  pregnancy,  83,  91,  215 
of  rupture  of  uterus,  472 
of  septicaemia,  584 
of  tubal  mole,  192 

Diagnosis,    differential.      See    Diffe- 
rential Diagnosis. 

Diameters,  conjugate,  external,  402 
of  foetal  head,  271 
pelvic,  257,  261,  401 
outlet,  404 

Diaphoretic  measures  in  eclampsia,  534 


INDEX 


763 


Diet  in  albuminuria,  125 
during  lactation,  619 
Differential   diagnosis    of    abdominal 
pregnancy,  195 
of  abortion,  229 

of  ante-partum  haemorrhage,  498 
of     backward     displacement     of 

uterus,  136 
of  pelvic  hsematocele,  194 
of  pregnancy,  96 
of  retroversion  of  gravid  uterus, 

136 
of  tubal  pregnancy,  192,  229 
Digestion  in  normal  pregnancy,  104 
Digestive  disturbances  of  artificially 
fed  infants,  631 
functions' in  the  puerperium,  548 
Dilatation  of  cervix,  233,  277,  392, 
504,  653 
of  OS  externum,  247 
of  OS  uteri,  222,  245 
Dilating  bag,  de  Ribes',  introduction 

of,  504 
Dilator,  small  hydrostatic,  501,  659, 

663 
Dilators,  branched  metal,  dilatation 
by,  in  induction  of  abortion, 
667 
Teuton's,  233 
Dorsal  position,  application  of  long 

forceps  in,  714 
Douches,  hot,  for  haemorrhage,  522 
Douching,  vaginal,  311 

risks  of,  556 
Douglas,  pouch  of,  blood  accumula- 
tion at,  191 
fibroids  in,  436 
Drugs  in  eclampsia,  536 

infiuencing  the  uterus,  231 
Ductless  glands,  123 

during  pregnancy,  77 
Diihrssen's  method  in  Caesarean  sec- 
tion, 720 

Eclampsia,  116 

bacterial  infection  of,  124 

complicating  labour,  diagnosis  of, 
529 
medical  treatment,  533 
prognosis,  530 
surgical  treatment,  539 
synopsis  of  treatment,  540 
treatment,  530 

conduct  of  labour  in,  538 

drugs  in,  536 

ductless  glands  and,  123 

etiology  of,  121 

hepatic,  121 

in  pregnancy,  113 

labour  complicated  by ,^527 

Uabihty  to,  115 

mortality  of  foetal  and  maternal, 
530 


Eclampsia — contd, 

pathological  anatomy  of,  117 

pressure  theories  of,  124 

renal,  121 

conditions  in,  118,  122 
tubules  from  case  of,  117 

surgical  treatment  of,  539 

toxaemia  of,  531 

treatment  of,  530,  533 

types  of  cases,  540 

uraemic  theory  of,  124 
Ectopic  pregnancy,  168 
Emboli  due  to  chorionic  villi,  35 
EmboHsm,  pulmonary,  sudden  death 

from,  in  the  puerperium,  613 
Embryo,  54 

development  of,  15,  54 
Embryonic  ectoderm,  12 
Embryotomy,  453 
Encysted    type    of    intra-peritoneal 

bleeding,  diagnosis  of,  191 
Endocervicitis,  gonorrhceal,  203 
Endocrinous  glands,  77 
Endometritis,  decidual,  157 

decidual  and  hydrorrhoea  gravi- 
darum, 158 

infective  puerperal,  572 

putrid  puerperal,  571 
Endometrium,  vertical  section  of,  7 
Enemata,  saline,  in  eclampsia,  534 
Entodermic  vesicle,  20 
Epilepsy,  diagnosis  of,  from  convul- 
sions in  eclampsia,  529 
Epiphysitis,  syphilitic,  168 
Episiotomy    in     face     presentation, 

441 
Epithelium  of  umbilical  cord,  53 
Ergot,  action  and  uses  of,  448 

administration  of,  in  post-partum 
haemorrhage,  522 

in  accidental  haemorrhage,  499 

injection  of,  336 
Erosion  of  cervix,  87 
Eruptions,  75 

Evisceration  of  foetus,  737,  749 
Evolution,  spontaneous,  stages  of,  382 

in  shoulder  presentation,  380 
Excretions  during  puerperium,  545 
Excretory     functions     during     preg- 
nancy, 78 
Exhaustion  from  obstructed  labour, 

461 
Exomphalos,  52 
Exostosis,  sacral,  431 
Expression  of  placenta,  334,  521 
Extension  of  foetal  head,  301 
Extra-uterine  gestation,  168,  188,  196 
Extremities,  prolapse  of,  393 

Face,  foetal,  diameters  of,  349 
Face  presentation,  344 

diagnosis  of,  347 

episiotomy  in,  441 


764 


INDEX 


Face  presentation— conit?. 

forceps  in,  717 

management  of,  354,  357 

mechanism  in,  348 

positions  in,  345,  349 
Facial  paralysis  in  new-born  child,  644 
Fallopian  tubes,  function  of,  3,  9 

gonorrhoeal  infection  of,  203 

gravid,  171,  172 

infection  of,  in  puerperal  infec- 
tion, 574 

removal  of,  734 
Feeding,  artificial,  621 

during  first  week  of  life,  617 

mixed, 627 
Female  pelvis,  255 
Femur,  left,  congenital  dislocation  of, 

due  to  oblique  pelvis,  428 
Fenton's  uterine  dilator,  233 
Fertilisation  and  implantation,  9 
Fever,  puerperal,  563 
Fevers,    acute    infectious,    associated 

with  pregnancy,  199 
Fibroid  polypi,  436 

tumours,  Csesarean  section  indi- 
cated by,  723 
Fibroids,     differential     diagnosis     of 
retroversion  and,  136 

sub-peritoneal,  435 

uterine,  influence  on  labour,  435 

and  pregnancy,  215 
Flat  pelvis,  396 
Fleshy  mole,  143 

four  weeks'  gestation,  146 
Flexion,  effect   of  wedge-shape  head 
on,  294 

explanations   of   movements   of, 
295 

in  face  presentation,  351 
Foetal  head,  after-coming,  application 
of  forceps  to,  717 

after-coming,  extended  or  flexed, 
376 

after-coming  in  breech  presenta- 
tion, 368,  412 

birth  of,  251 

crushing  of,  741,  743,  745 

decapitation  methods,  746 

delivery  of,  329,  354,  375 

diameters  of,  271 

effect  of  labour  upon,  304 

"  engaged,"  323 

expulsion    of,    extension    move- 
ment of,  301 

extension  of,  330 

extraction  by  axis-traction  for- 
ceps, 709 

extraction  of,  743 

jSexion  of,  292,  296,  351 

girdle  of  contact,  271 

injuries  of,  643 

in  upper  part  of  pelvic  cavity,  711 

level  of,  during  first  stage,  323 


Fcetal  head — contd. 

methods  of  perforating,  739 
moulding  of,  304,  342,  349 

after    face    presentation    in 

abnormal  labour,  353 
extreme,  414 

extreme,     from     labour    in 
generally   contracted   pel- 
vis, 414 
in  flat  pelvis,  412 
ossification  of,  269 
pelvic      brim,      and     bi-manual 
method  of  estimating  size  of, 
421 
relation  to  pelvis,  290 
rotation  of,  297,  339,  710 
shape  of,  271 
sutures  of,  269 
wedge  shape,  294,  411 
Foetal  heart,  auscultation  of,  318 
sign  of  pregnancy,  94 
sounds,  maximum  intensity  of,  in 
vertex    and    breech    presenta- 
tions, 320 
Foetus,  54 

abdominal        enlargement       ob- 
structing  labour,   460 
abnormal  conditions  of,  167 
ascites,  460 
attitude  of,  265,  267,  345 

in  spontaneous  evolution,  380 
axis  pressure,  285 
circulation,  58 

changes  in,  at  birth,  60 
complications,  use  of  forceps  in, 

702 
compressus,  102 
death  of,  195,  236 
causes  of,  120 
in  albuminuria,  115,  116 
in  eclampsia,  120 
in  ulero,  236,  239 
version  of,  671,  675 
destruction  of,  737 
disease  transmitted   to,  43,  168, 

200 
diseases  of,  159,  633 
disposition  of,  in  normal  labour, 

266 
eclampsia  and,  120 
evisceration  of,  737,  749 
excretory  organs  of,  61 
extension  of  trunk,  300 
extraction  of,  after  craniotomy, 
740 
after  decapitation,  748 
in  Csesarean  section,  727 
extra-uterine,  retention  in  abdo- 
men, 185,  196 
forceps  injuries  of,  718 
found  in  moles,  147 
heart  sounds  of,  93,  318 
influence  on  labour,  243 


INDEX 


765 


Foetus — contd. 

intra-uterine    manipulations    of, 

465 
labour  obstructed  by,  456 
liver  of,  61 
maceration  of,  238 
mature,  57 

monthly  growth  of,  56 
mortality  in  eclampsia,  530 
mummified,  102 
normal  labour  and,  266 
nutrition  of,  43,  51,  61 
obstetric  injuries  of,  633 
oedema  of,  459 
palpation  of,  314 
papyraceus,  102,  238 
physiology  of,  61 
positions  of,  345,  349 
positions  with  vertex  presenting, 

286 
presentations     in     twin    labour, 

386 
respiration  in,  60 
retention  of,  236 
risks  to,  in  breech  presentation, 

366 
rotation  of,  341 
showing     normal     attitude      of 

flexion,  265 
size  of,  228 
skull  of,  268 

See  also  under  Foetal  Head, 
spontaneous  movements,  92 
syphihs  of,  201 
viability  of,  57 
weight  and  size  of,  57 
Fontanelles,  269 

in  vertex  presentation,  324 
posterior,  detection  of,    in  nor- 
mal labour,  324 
Food  tests,  620 
Foot,  prolapse  of,  393 

seizing   in   transverse    presenta- 
tions, 681,  683 
Forceps,  application  and  use  of,  341, 
703 
application  to  after-coming  head, 

717 
axis-traction,  application  of,  703, 
705 
apphed  to  head,  694 
delivery  by,  710 
extraction  of  head,  709 
introduction  of  blades,  706, 

708 
locking  of  blades,  707 
Murray's,  693 
Neville's,  697 
traction  with,  709,  712 
Walcher's      position,      711, 

713 
when    pelvis   is    contracted, 
712 


Forceps,  axis-traction — contd. 

with  head  in  lower  part  of 

cavity,  705 
with  head  in  upper  part  of 
cavity,  711 
cephalic  and  pelvic  curves  of,  691 
Chamberlen's,  different  patterns 

of,  689 
De  Ribes',  666 
double    slot,   lock    and    shanks, 

619 
in  face  cases,  717 
in  pelvic  contraction,  702 
long,  application  in  dorsal  posi- 
tion, 714 
applied  to  head,  692 
introduction  of  blades,  716 
use  of,  714 
long  or  curved,  692 
Murray's  axis-traction,  693 
Neville's  axis-traction,  697 
obstetric,  689 

modes  of  action  of,  697 
operation,  risks  of,  718 
ovum,  235 

short  or  straight,  690 
straight,  applied  to  head,  690 
use  of,  indications  for,  699 
Fracture,  fissured,  of  skull,  644 
Fractures  of  bones  of  head,  642 

of  limbs  from  unskilled  delivery, 
645 
Fritsch,  incision  of,  733 
Funnel-shaped  pelves,  429 


Gastro-enteritis,   acute,   from   un- 
suitable feeding,  632 
Gastro -intestinal  haemorrhage,  648 
Gestation.     See  Pregnancy. 
Gigantism,  foetal,  459 
Gigli's  saw,  754 

Girdle  of  contact,  diameters  of,  271 
Glands,  endocrinous,  77 

mammary,  71 

inflammation  of,  603,  605 
Glass,  intra-uterine  douche  nozzle,  589 
Glass    tube    for    carrying    sterilised 

bougies,  662 
Gonorrhoea,  pregnancy  and,  202 
Graafian  folhcle,  ripening  and  rupture 
of,  1,  2 

site  of  implantation,  169 
Grip,  Mauriceau-Veit,  369 

Prague,  370 

Smellie,  370 


H^MATOCBiiB,  pelvic,  192 

differential  diagnosis  of,  194 
in  mesial  sagittal  section,  193 
treatment  of,  197 

Hsematocele,  peri-  and  para-tubal,  194 


766 


INDEX 


Hsematoma  mole,  143 
pelvic,  192,  479 
vaginal,  479 
vulval,  479 
Hsematosalpinx,  177,  194 

tubal  abortion  with,  186 
Haemorrhage,    accidental,    484,    488, 
496 
treatment  before  labour,  499 
treatment  of,  507 
amount   and  rapidity    in    tubal 

pregnancy,  188 
ante-partum,  in  abnormal  labour, 
483 
causation,  484 
differential  diagnosis  of,  498 
morbid  anatomy  of,  491 
symptoms      and      influence 
upon  labour,  495 
arrest  of,  by  de  Ribes'  dilating 

bag,  504 
bi-manual  compression  in,  525 
clinical  feature  of  abortion,  221 
concealed  accidental,  493,  497 
concealed  treatment  of,  509 
control  of,  in  Csesarean  section, 

730 
diffuse,  189 

during  normal  labour,  278 
encysted  internal,  191,  197 
external  accidental,  497 
from  head,  as  a  result  of  injury 

during  labour,  641 
from  inertia,  treatment,  520 
from   lacerations,   treatment   of, 

525 
gastro -intestinal,  648 

treatment,  649 
in  hydatidiform  mole,  155 
in  threatened  abortion,  223 
in  tubal  rupture,  179,  182 
internal,  diffuse  type,  in  extra- 
uterine   pregnancy    treat- 
ment, 196 
in     tubal    pregnancy,    185, 
187 
intra -cranial,  642 
intra-peritoneal,  diffuse  type  of, 
189 
encysted  type  of,  191 
of  placenta,  166 
post-partum,  518 

causation  of,  518 
diagnosis,  520 
puerperal,  606 
secondary  post-partum,  606 
separation  of  placenta  by,  280 
temporary  arrest  of,  500 
unavoidable,  484,  488 
Hand,  prolapse  of,  393 
Hands  and  forearms,  sterilisation  of, 
in  management  of  normal  labour, 
309 


Head,  after-coming,  368,  376,  412 
and  arm,  presentation  of,  394 
birth  of,  scalp  appearing  at  vulva 
in  normal  labour,  251 
vulva  completely  dilated  in 
normal  labour,  252 
delivery  of,  difficulty  in  breech 
presentation,  375 
in  face  presentation  in  ab- 
normal labour,  354 
extension  of,  in  normal  labour,  300 
in  passing  pelvic  outlet,  330 
flexion  of,  in  face  presentations  in 
abnormal  labour,  351 
in  normal  labour,  292 
injuries  to,  during  labour,  641 
internal  rotation  of,  297 
moulding  of,  304,  353,  414 
presentation,  672 
wedge  theory  in  normal  labour, 

294,  411 
See  also  Foetal  Head. 
Heart,  changes  in,  in  eclampsia,  120 
diseases  of,  pregnancy  and,  203 
foetal,  sounds  of,  94,  319,  362 
in  pregnancy,  76 
in  septicaemia,  583 
stimulation  of,  526 
valvular  disease  and  pregnancy, 
204 
Hebotomy,  753 
Hegar's  sign  of  pregnancy,  88 
Heredity  and  multiple  pregnancy,  97 
Hernia,  congenital  ventral,  52 

of  gravid  uterus,  140 
Herpes  gestationis,  132,  213 
Heterogenetic  infection,  568 
Hicks'  (Braxton)  cephalotribe,  741 
method  of  bi-polar  version,  687 
Hip-joint,  disease  of,  obUque  pelvis 

due  to,  428 
Hooks,  decapitation,  741,  746,  748 
Hormone,  pregnancy,  74 
Hour-glass  contraction  of  uterus,  513 
Human  milk,  composition  and  charac- 
ter of,  618 
Hydatidiform  mole,  148 
causation  of,  154 
clinical  features,  155 
diagnosis  of,  156 
malignant,  154 
section  through  a  chorionic  villus, 

153 
treatment,  156 
Hydramnios,  147,  159,  359 

OUgo-,  161 
Hydrocephalus,  359 

labour  obstructed  by,  456 
management  of  labour  in,  458 
Hydrorrhoea  gravidarum  and  decidual 

endometritis,  158 
Hydrostatic  dilating  bag  of  de  Ribes, 
501,  505 


INDEX 


767 


Hydrostatic  dilator,  small,  659,  663 
Hyperemesis  gravidarum,  126 
Hysterectomy,  Csesarean,  735 
prognosis  of,  725,  736 
reasons  for,  724 
Hysteria,    differential    diagnosis    of, 

529 
Hysterical  vomiting,  126 
Hystero-epilepsy,  529 


Icterus  neonatorum,  648 

Incision,  abdominal,  726 

Incubator     for    premature    infants, 

630 
Inertia,  post-partum,  causes  of,  519 
uterine,  treatment  of  haemorrhage 
from,  520 
Infantile  syphilis,  650 
Infants,  artificial  feeding  of,  digestive 
disturbances  in,  631 
feeding,  effect  on  weight,  620 
premature,  incubator  for,  630 

management  of,  628 
weight  of,  620 
Infarction,  pathological,  of  the  pla- 
centa, 165,  488 
Infection,  puerperal,  563 

autogenetic  infection,  567 
bacteria  of,  664 
causation,  564 
channels  of  infection  in,  568 
chnical  varieties  of,  575 
heterogenetic  infection,  567 
mixed  infection,  567 
pathological  anatomy  of,  571 
powers  of  resistance  to,  569 
specific  organisms  of,  566 
Infections,   chronic,   and   pregnancy, 

200 
Inflammation,  acute  tubal  or  ovarian 
in  puerperium,  597 
local  pelvic,  594 
Injection  of  saline  solution  in  treat- 
ment of  post-partum  haemor- 
rhage, 526 
in  treatment   of  convulsions  in 
eclampsia,  533 
Insanity,  reproductive,  in  puerperium, 

611 
Insufflation,  in  artificial  respiration, 

639 
Insufflator,      Ribemont  -  Dessaignes', 

640 
Intercristal  diameter  of  pelvis,  401 
Internal  ballottement,  sign  of  preg- 
nancy, 91 
Interspinous  diameter  of  pelvis,  401 
Intra -peritoneal  bleeding  diffuse  type 
of,  189 
encysted  type  of,  191 
Intra-uterine  bougie  for  induction  of 
abortion,  661 


Inversion  of  uterus  in  labour,  480 

causes  of,  480 

diagnosis  of,  481 

induced,  481 

prognosis  of,  482 

symptoms  of,  481 

treatment  of,  482 
Involution  of  uterus  in  the  puerperium, 

548 
Ischial    planes,    controlling   internal 

rotation,  413 
Ischium,  inclined  planes  of,  300 

Johnson's  method  of  pelvimetry,  408 

Kidneys,  changes  in,  in  eclampsia,117 
decapsulation   of,  .  in   eclampsia, 

535 
diseases   of,   in   pregnancy,    113, 

116,  118,  122,206 
right,  in  pyolitis,  209 
right,   predisposition   to   disease, 
209 
Klebs-Loffler  bacillus,  566 
Knee-chest  position  in  treatment  of 

presentation  of  cord,  391 
Knee-elbow  position  in  treatment  of 

presentation  of  cord,  392 
Krause's    method    of    induction    of 

abortion,  661,  663 
Kyphotic  pelvis,  429 

Labotjb,  abnormal,  343 

abnormahties  in  action  of  uterus 

in,  442 
ante-partum  haemorrhage  in,  483 
symptoms  and  influence  of, 
495 
ante-partum    rupture    of    mem- 
branes in,  453 
attitude  of  the  foetus,  345 
breech  or  pelvic  presentations  in, 

358 
brow  presentations  in,  356 
Csesarean     section     before     and 
after,  732 
during,  724 
compUcated  by  eclampsia,  527 
diagnosis  of,  529 
general  principles  of  treat- 
ment, 531 
medical  treatment,  533 
occurrence,  527 
prognosis,  530 
surgical  treatment,  539 
synopsis  of  treatment,  540 
treatment,  530 
conditions  of  soft  parts  and,  433 
conduct  of,  in  eclampsia,  538 
contracted  pelves,  409 

management  of,  414 
diagnosis     of     pelvic     tumours 
during,  433 


768 


INDEX 


Labour,  abnormal — confd. 

effect    of    overaction    of    uterine 

muscle  on,  454 
face  presentation  in,  344 

diagnosis  of,  347 

management  of,  354 

mechanism,  348 
false,  184,  195 
fiat  pelvis,  410,  411 
inversion  of  uterus  in,  480 
management  of,  500 
mechanism  of,  in  breech  presenta- 
tion in  iiat  pelvis,  412 

in  generally  contracted  pel- 
vis, 413 
non-expulsion  of  placenta  in,  510 
obstructed,  455 

by  fibroid  tumour,  436 

by  hydrocephalus,  456 
obstruction  of,  clinical  results,  461 
ovarian  cyst  obstructing,  434 
pelvic  contraction  and,  394 
l^rolapse   of  umbihcal   cord   and 

limbs  in,  389 
rupture  of  uterus  in,  462 
transverse  or  shoulder  presenta- 
tions, 377 
treatment  of  accidental  hsemor- 

rhage  before,  499 
twin  labour,  386 
Labour,  normal,  241 
age  factor  in,  241 
chloroform  during,  327,  329 
date  of,  241 

diagnosis  and  general  course  of, 
in  occipito-posterior  positions 
of  vertex,  338 
displacement  of  pelvic  floor  in,  262 
effect  of,  upon  the  foetal  head,  304 
first  stage,  duration  of,  248 
first  and  second  stages,  maternal 

passages  and,  254 
foetal  positions  in,  287 
foetus  and,  266 
forces  of,  273 
general  effects  of,  278 
haemorrhage  during,  278 
labour  centre,  278 
liquor  amnii  in,  272 
management  of,  308 

abdominal  palpation  in,  312 

antiseptics  in,  308 

diagnosis,  312 

first  stage,  325 

preparations,  308 

second  stage.  327 

third  stage,  331 
mechanism  of,  284 
nerve  centre  of,  278 
stages  of,  246 
stage  of,  first,  247 

second,  248 

second,  birth  canal  in,  275 


Labour,  normal — contd. 
stage  of,  third,  253 
onset  of,  243 
pains  of,  243 
Labour,  ovariotomy  during,  435 
precipitate,  400,  442 
premature,  242 

in  albuminuria,  116 
induction  of,  651,  652 

in  pelvic  contraction,  41 9 
postmature,  242 
second  stage,  expulsion,  248 

prolonged,  use  of  forceps  in, 
700 
third  stage,  anatomv  and  phvsio- 

logy  of,  279 
vaginal  examination  during,  321, 
347 
Lacerations  in  forceps  operation,  718 
hsemorrhage  from,  treatment,  525 
Lactation,  diet  and  hvgiene  during, 
619 
process  of,  559 
Langhans,  cells  of,  39 
islets  of,  39 
layer  of,  32,  37 
Leg,  prolapse  of,  393 

pulling  down  in  placenta  prsevia, 

501 
white,  598 
Leopold's  ovum,  29 
Leucocytosis,  547 

Limbs,  fractures   of,   from   unskilled 
deUvery,  645 
prolapse  of,  in  abnormal  labour, 
389,  393 
Lime  salts,  excretion  of,  79 

water  as  diluent,  624 
Lipoid  substances  in  blood,  110 
Liquor  amnii,  composition  of,  49 
escape  of,  247,  253 
function  of,  51 
in  normal  labour,  272 
Lithopcediou,  185,  196 
Liver,  changes  in,  in  eclampsia,  118 
diseases  of,  pregnancy  and,   78, 

211 
foetal,  size  of,  58,  61 
Lochia,   as   channel   of   infection   in 

puerperal  infection,  568 
Lochial  discharge  in  the  puerperium, 

554 
"  Longings  "  in  pregnancy,  77,  104 
Lozenge  of  ^lichaehs,  403 
Lutein  cells,  5 

Malaeia  in  pregnancy,  203 

Male  pelvis,  256 

Malformation  of  uterus,  and  preg- 
nancy, 141 

Mahgnant  uterine  disease  and  preg- 
nancy, 217 

Malnutrition,  signs  of,  75 


INDEX 


769 


Mammals,  lower,  amnion  in,  develop- 
ment of,  14 
Mammary  abscess,  603 
Mammary  glands,  71 

actuation  in  pregnancy,  73 
inflammation  of,  603 

treatment,  605 
pigmentary  changes  in,  72 
Manipulation,  in  treatment  of  back- 
ward displacement  of  uterus,  138 
Mastitis,  603 
Maternal  complications,  use  of  forceps 

in,  701 
Mauriceau-Veitgrip  in  breech  presen- 
tations, 369,  370,  371 
Meals,  test  feeds  for  infants,  620 
Meconium,  amount  of,  617,  620 
Melsena  neonatorum,  648 
Membranes,  ante-partum  rupture  of, 
453 
management  of,  455 
delivery   of,   in   normal    labour, 

334 
diseases  of,  159 
morbid  adhesion  of,  512 
necrosis  of,  239 
rupture  of,  247,  506 

in  induction  of  abortion,  661 
twin,  99 
Menstrual  decidua,  8 
Menstruation,  6 
anatomy  of,  8 
arrest  of  in  pregnancy,  84 
arrest     of,     due     to      operative 

methods,  734 
effect  on  lactation,  619 
Mental  disturbances  in  pregnancy,  132 
Mento-vertical    plane,    position    and 

shape  of,  357 
Mercurial  salts,  311 
Mercury,    poisonous    absorption    of, 

from  douching,  557 
Metabolism,  carbohydrate,  109 

in  pregnancy,  79 
Metritis,  573 

Metrorrhagia  in  tubal  pregnancy,  187 
Milk,  ass's,  composition  of,  621 
cow's,  comjjosition  of,  621 
cream  of,  624 
modification  of,  623 
XDasteurisation  of,  623 
iwoteids  of,  622,  624 
steriUsation  of,  623 
human,  73 

composition  and  character  of, 

618,621 
daily  amount  secreted,  619 
elements  of,  560 
Milk  steriUser,  Soxhlet's,  625 
Miscarriage.     See  Abortion. 
Mole,  blood,  143 
fleshy,  146 
hydatidiform,  148 

E.M. 


Mole — contd. 
tubal,  174 

chorionic  villi  in,  176 
uterine,  143 

causation  of,  154 
clinical  features  of,  155 
symptoms,  148 
vesicular,  148,  150 
Monsters,  98,  100,  167 

double,  460 
Morning  sickness,  symptom  of  preg- 
nancy, 85 
Morphia  in  convulsions  in  eclampsia, 

537 
Mortality  of  breech  presentation,  367 
of  Caesarean  operations,  540,  736 
of  eclampsia,  530 
of  forceps  operation,  718 
of  puerperal  infection,  564 
of  symphysiotomy,  753 
Mouse,  process  of  fertilisation  in,  10 
Multipara,  241 
Mummified  foetus,  102 
Muriform  body,  11 
Murray's  axis-traction  forceps,  693 
Muscle,  uterine,  changes  in,  68 
Myxo-fibromata,  placental,  166 


Nagele's      obliquity      or      anterior 
asynclitism,  290,  291 

pelvis,  426 
Navel.     See  UmbiUcus. 
Necrosis,  massive,  109,  119 
Nephritis  in  pregnancy,  206 
Nephrotomy  in  pyeUtis,  211 
Nervous  disturbances,  effect  on  lacta- 
tion, 619 

excitement,  rise  of  temperature 
due  to,  544 

system  in  pregnancy,  77,  211 
Neuritis,  pregnancy  and,  211 
Neville's  axis-traction  forceps,  697 
New-born  child,  615 

breast  feeiing  of,  617 

care  of,  616 

general  management  of,  615 

skin  of,  621 
Nipples,  cracked  or  sore,  562 

preparation  for  suckUng,  561 
Nitrogen,  urinary  excretion  of,  109 


Obstetric  forceps,  689 

injuries  and  diseases  of  the  foetus, 

633 
modes  of  action  of,  697 
operations,  651 
sterihser,  309 
Occipito-anterior  position,  axis-trac- 
tion forceps  in,  713 
Occipito-frontal  plane,   position   and 
shape  of,  in  normal  labour,  298 

49 


770 


INDEX 


Occipito-posterior  position,  difficulty 
in  delivering  head  in,  338 
usual   moulding,  in    normal 
labour,  342 
of  vertex  in  normal  labour,  299 
management  in,  339 
mechanism,  337 
diagnosis  and  general  course 

of  labour  in,  338 
in  normal  labour,  337 
Occiput,    backward    rotation    of,    in 
normal  labour,  299 
forward   rotation   of,   in  normal 
labour,  298 
Olldema,  foetal,  459 
in  pregnancy,  206 
of  placenta,  166 
Ohgo  hydramnios,  161 
Oocyte,  human,  3 
Operations,  obstetric,  650 
Ophthalmia  neonatorum,  646 
prevention  of,  615 
treatment,  647 
Opium  in  threatened  abortion,  231 
Opsonins,  591 
Os  externum,  dilatation  of,  247.     See 

also  Cervix. 
Ossification  of  foetal  skull,  269 
Osteomalacic    pelvis,    advanced    de- 
formity of,  424 
pseudo-,  425,  426 
with  moderate  deformity,  424 
Os  uteri,  dilatation  of,  symptom    of 
abortion,  222 
internal,  dilatation  of,  in  normal 
labour,  245 
Ovarian  cyst  obstructing  labour,  434 
cystic  tumours,  154 
jDregnancy,  169 
tumours,  433 

Csesarean    section   indicated 

by,  723 
pregnancy  and,  214 
Ovaries,    infection    of,    in    puerperal 
infection,  574 
removal  of,  734 
Ovariotomy  during  labour,  435 
Over-distension  of  lower  uterine  seg- 
■  ment,  463 
Ovulation,  1 
Ovum,  apoplectic,  147 
Bryce-Teacher,  16 
complete,  31 

ninth  week,  49 
from  fourth  or  fifth  week,  48 
three  months'  development, 
retained  after  death,  237 
condition  of  in  abortion,  228 
detached  in  abortion,  222 
embedding  of,  19 
expulsion  of,  in  tubal  abortion, 

179 
extra-embryonic  portion  of,  12 


Ovum — contd. 

fertiMsation  of,  9,  11 

fertihsed,  lodged  in  fallopian  tube, 

173 
forceps,  235 
implantation  of,  9 
Leopold's,  29 
nutrition  of,  20,  30 
Peters',  18 
segmentation  of,  11 
Spee's  section  of,  27 
Teacher-Bryce,  16 


Pain,  abdominal,  in  intra-peritoneal 
haemorrhage,  189,  191 
clinical  feature  of  abortion,  221 
in  bacillus  coli  infection,  208 
in  labour,  243 
Pains,  "  bearing-down,"  252 

character  of,  330,  339 
Pajot's  manoeuvre,  696 
Palpation,  abdominal,  312, 378 

in  transverse  presentation,  378 
Panhysterectomy,  735 
Paralyses,  birth,  644 
Paralysis,  facial  in   new-born    child, 
644 
of  arm,  645 
Parametritis,  595 
Parietal  obhquity,  290 
Parturient  canal,  fully  dilated,  264 

uterus,  273 
Parturition.     See  Labour. 
Pasteurisation  of  milk,  623 
Pelvic   arch,  width  of,  estimation  by 
palpation,  403 
axis,  263 

bones,  tumours  of,  432 
cavity,  breech  arrested  in,  373 
cellular  tissue,   inflammation    of 

and  puerperal  infection,  574 
celluhtis,  595 

contraction,  forceps  in,  702 
floor,  displacement  of,  in  labour, 
262 
rigidity     of,     in     abnormal 
labour,  441 
hsematoma,  479 

inflammation,    common   features 
of,  595 
local,  594 

treatment  of,  598 
organs  in  septicaemia,  583 
peritonitis,  596 
presentations,  358 
tumours,  diagnosis  of,  433 
veins,  infection  of,  in  puerperal 
infection,  575. 
ligature    or   excision    of,    in 
pysemia,  602 
See  also  under  Pelvis. 
Pelvimeters,  401,  407 


INDEX 


771 


Pelvimetry,  clinical,  401,  408 
external,  402 
internal,  405 
Pelvis,  anatomy  of,  254 

anterior-posterior     diameter     of 

outlet,  404 
cavity  of,  259 
conditions    for    symphysiotomy, 

750,  752 
contracted,  409 

and  abnormal  labour,  394 
Csesarean  section  in,  722. 
craniotomy  in,  738,  740 
diagnosis,  400 
generally,  395 

mechanism     of     labour 

and,  413 
Walcher's    position    in, 
713 
labour  and,  409 
management  of  labour  in,  414 
pregnancy  and,  409 
rare  forms  of,  423 
diagonal  conjugate  of,  405 
diameters  of,  description,  257, 261 
diameters  of  outlet,  404 
effect  of  pubiotoniy  on,  753 
enlarged,  generally,  400 
false,  255 
female,  255 

outlet  of  pelvic  brim,  257 
flat,  396 

axis-traction  forceps  in,  712 
labour  and,  410,  411 
outlet  of,  399 
rachitic,  397 
varieties  of,  399 
floor  of,  displacement  in  labour, 
262 
.    sloping,  298 
funnel-shaped,  429 

delivery  of  head  in,  714 
internal  measurements,  405 
kyphotic,  429 
male,  256 

measurements  of,  external,  401 
external  conjugate  diameter, 

402 
intercristal  diameter,  401 
interspinous  diameter,  401 
jSTagele's,  426 

normal,  planes  aiid  axes  of,  260 
oblique,     congenital    dislocation 
due  to,  428 
due  to  disease  of  hip-joint, 
428 
osteomalacic,  advanced  deformity 
of,  424 
with  moderate  deformity,  424 
outlet  of,  258 

or  lower  pelvic  strait,  258 
pal]3ation  of,  403 
pseudo-osteomalacic,  425,  426 


Pelvis — contd. 

relation  of  foetal  head  to,  290 

Robert's,  427,  428 

scoliotic,  431 

spondylolisthetic,  431   ' 

transverse  diameter  of,  405 

See  also  under  Pelvic. 
Peptones,  placental,  81 
Perforation  in  craniotomy,   methods 

of,  738 
Perforators,  method  of  using,  739 
Perimetritis,  573,  596 
Perineum,  lacerations  of,  types,  755, 
757 

primary  repair  of,  754 

rupture  of,  480 

supporting,  329 
Peritoneum,  infection  of,  in  puerperal 

infection,  574 
Peritonism,  190 
Peritonitis,  pelvic,  573,  596 

puerperal,  general,  594 
Pernicious  vomiting,  126 
Peroxide  of  hydrogen  douch,  311 
Peters'  ovum,  18 

embryonic  area  in,  21 
Phlebitis,  573,  575 
Phlegmasia  alba  dolens,  598 

chart  of  case,  601 

clinical  features,  599 

forms  of,  598 

treatment,  600 
Phlegmon,  broad-ligament,  574 
Phthisis,  pregnancy  and,  200 
Pigmentary  changes  in  pregnancy,  72, 

75 
Pituitary  extract,  value  of,  in  obste- 
trics, 447 
Pituitary  gland,  hypodermic  infection 

of,  526 
Placenta,  anomalies  of  size  and  shape, 
162 

at  term,  44 

attachments  of,  scheme,  39 

bipartite,  162 

circulation  through,  40 

degeneration  of,  166,  206 

delivery  of,  253 

compression    of    fundus     to 
empty  uterus  after,  336 

diffusa,  163 

digital  removal  of,  515 

diseases  of,  159,  161 

expression  of,  334,  521 
in  normal  labour,  335 

expulsion  of,  333 

foetal  surface,  45 

formation  of,  30 

fully  developed,  of  eight  months, 
36 

function  of,  43,  61 

haemorrhage  of,  166 

insertions  of  umbilical  cord,  54 


772 


INDEX 


Placenta — contd. 

maternal  circulation  through,  40 

morbid  adhesions  of,  512,  517 

multiloba,  162 

necrcigis  of,  239 

non-expulsion  of,  510 

numbers  of  vilh  in,  36 

oedema  of,  166 

pathological  infarction  of,  165 

quick,  comphcating  operation,  198 

retention  of,  511,  517 

due  to  contraction  ring,  514 

separation    of,    by  formation   of 
retro-placental  clot,  280 
from  below  upwards,  282 

seven   months,  section  through, 
38 

succenturiata,  162,  163 

syphihs  of,  166 

treatment  of,  in  Csesarean  section, 
729 
in  secondary  abdominal  preg- 
nancy, 198 

tripartite.  162 

triplet,  103 

tubercle  of,  166 

twiQ,  98 

uterine  suiface,  46 

villi  in,  36 

A-illus  attached  to  decidua,  37 

with  extensive  haemorrhage,  151 
Placenta  and  chorion,  27 
Placenta  prsevia,  69,  360 

basal,  484 

Csesarean  section  in  treatment  of, 
507 

central,  491 

comparison  of  methods  of  treat- 
ment, 505 

differential  diagnosis  of,  498 

hfemorrhage  due  to,  death  from, 
487 

lateral,  492 

mortahty  of,  510 

pulling  down  a  leg  in,  501 

severe  cases  of  treatment,  500 

shght  cases  of  treatment,  506 

treatment  of,  499 

version  in,  505 
Placental  toxsemia,  112,  122 
Placentitis,  161 
Planes  and  axes,  foetal  head,  297,  357 

pelvic,  260,  263 
Plasmodi-trophoblast,  19 
Pleurisy  in  septicaemia,  583 
Plugging  the  cervix,  506 

the  uterus,  524 

the  vagina,  508 
Pneumonia  in  septicsemia,  583 
Polyhydramnios,  159 
Polypus,  intra-uterine,  229 
Porro's  operation,  720 
Prague  grip,  370 


Pregnancy,  Abderhalden's  test  in,  81 
abdominal,    retention    of   foetus, 
185,  196 

secondary,  194 
abnormal,  106 
acute  infectious  fevers  associated 

with,  199 
age  factor  in,  83 
albuminuria  during,  113 

etiology,  120 

treatment,  124 
appendicitis  and,  213 
artificial  interruption  of,  651 
bacillus  coh  infection  and,  207 
bladder  irritabihty  in,  78,  86 
chronic  infections  and,  200 
circulatory  system  in,  76 
contracted  pelves  and,  409 
diabetes  and,  211 
diagnosis  of,  83 

during  first  haK,  sjTnptoms, 
84 

during    second    half,     sym- 
ptoms, 91 

in  fibroid  tumours  of  uterus, 
215 
differential  diagnosis  of,  96 
diseases  of  liver  and,  211 
diseases  of  nervous  system  and, 

211 
disorders  associated  with,  199 
disorders  of,  107 
ductless  glands  in,  77 
duration  "of,  84,  241 
eclampsia  in,  113 
eighth  week  of,  87 
excretory  functions  during,  78 
extra-uterine,  168 

diagnosis  of,  196 

unruptured,    treatment     of, 
196 
face  presentation  in,  344 
fibroids  and,  215 
general  physiological  changes  in, 

71 
gonorrhoea  and,  202 
Hegars  sign  of,  88 
hydrocephalus  in,  457 
hydrorrhoea  in,  158 
hygiene  of,  104 
in  rudimentary  left  uterine  horn, 

141 
influence  of  venereal  diseases  on, 

201 
intra-hgamentary,  182,  184 
intra-peritoneal,  183 
isthmial,  182 
malaria  and,  203 
malformation  of  uterus  and,  141 
mahgnant  uterine  disease  and,217 
mammary  gland  changes  in,  72, 

74 
metabohsm  in,  79 


INDEX 


773 


Pregnancy—  contd. 
"multiple,  97 

nausea  and  vomiting  in,  78,  85 
nervous  disturbances  of,  77 
normal,  1 

management  of,  104 
ovarian,  169 

ovarian  tumours  and,  214 
period  of,  determination  of,  95 
peritoneal,  primary,  168 
phthisis  and,  200 
physical  signs  of,  87 
pregnancy  symptoms  in,  142 
pyelitis  of,  207 
renal  diseases  in,   113,  116,  118, 

206 
second  half  of,  physical  signs,  92 
secondary  abdominal  intra-liga- 

mentary,  183 
serum  reactions  in,  80 
sixteenth  week  of,  89 
spurious,  94 
•    syphilis  and,  200 
table  of,  57 
thirty-sisth  week,  95 
toxaemias  of,  80,  108 
tubal,  171 

anatomy,  171 
clinical  features  of,  185 
differential  diagnosis,  229 
ruptured,  179 

section    of     ovum     in    situ, 
144 
twin,  97 

cHnical  course,  101 

urinary  excretion  during,  78 

Premature   infants,   management   of, 

628     •      - 
Presentation,  abnormal,  344 

positions  of,  in  normal  labour,  295 
transverse,  674 
vertex,  in  normal  labour,  286 
Pressure,  continuous,  in  treatment  of 
backward      displacement      of 
uterus,  138 
direct     intra-uterine     or     foetal 

axis  in  normal  labour,  285 
intra-uterine,  general  or  indirect 

in  normal  labour,  284 
symptoms  in  pregnancy,  142 
Primipara,  241 

breech  presentations  in,  371 
posterior  asynchtism  in,  290 
rigidity  of  cervix  in,  438 
Prognosis  of  hysterectomy,  725,  736 

of  symphysiotomy,  753 
Pronucleus,  male  and  female,  11 
Proteids,  milk,  622,  624 
Pruritis  in  pregnancy,  131 
Pseudocyesis,  96 

Pseudo-osteomalacic  pelvis,  425,  426 
Ptyahsm,  131 
Pubiotomy,  753 


Puerperal  disease,   following  forceps 
operation,  718 

endometritis,  infective,  572 
jjutrid,  571 

hemorrhage,  606 

infection,  563 

mortality  of,  664 

peritonitis,  general,  594 
Puerperium,  542 

after-pains  in,  555 

chorionepithelioma  in,  607 

general  physiology  of,  542 

hygienic  measures  during,  558 

involution  of  uterus  in,  548 

lochial  discharge  in,  554 

management  of,  556  . 

normal,  543 

"  rational,"  559 

reproductive  insanity  in,  611 

saprsemia  in,  579 

septicaemia  in,  581 

structural  changes  in  the  uterus 
in,  552 

sudden  death  in,  613 

temperature  in,  543 
Pulmonary  abscesses  in  septicaemia, 

583 
Pulse  in  septicaemia,  582 
Pulse-rate  in  the  puerperium,  545 
Purgation  in  eclampsia,  535 
Purgatives,  administration  of,  535 
Purin  bodies,  79 
Pyemia,  602 

Pyelitis  of  pregnancy,  207 
Pyogenic  organisms,  565 
Pyrexia  of  eclampsia^  treatment,  538 


Quadruplets,  97 
Quickening  in  pregnancy,  86 
Quintuple  pregnancy,  97 


Rachitic  flat  pelvis,  396,  397,  398 
Radiography  of  the  pelvis,  408 
Ramsbotham's  hook,  746 
Rectification,  spontaneous,  380 
Renal  diseases,  pregnancy  and,  206 
Respiration,    artificial,    methods    of, 
636 
Schultze's  method  of,  636,  637 
Sylvester's  method  of,  638 
Rest  in  the  puerperium,  557 
Restitution  and  external  rotation  of 

foetus,  303 
Retraction  of  uterine  wall,  276 
Retraction  ring,  uterine,  275 
Retroflexion,  132 
Retroversion,  132 
Rhomboid  of  Michaelis,  403 
Ribemont-Dessaignes'  insufflator,  640 
de  Ribes'  dilating  bag,  introduction 
of,  504 


774 


INDEX 


Rigidity  of  cervix  in  abnormal  labour, 
438 
of  pelvic  floor  in  abnormal  labour, 
441 
Robert's  pelvis,  427,  428 
Rotation,  backward,  of  occiput,  299 
external,  304,  352 

and  restitution,  303 
position  of  shoulders  before, 
302 
forward  of  occiput,  298 

spontaneous,  339 
of  foetal  head,  349,  352 
of  head  in  flat  pelvis,  411 
internal,  297 

in  breech  presentation,  364 
ischial  planes  controlHng,  413 
manual,  340 
Routh's  statistics  cf  Csesarean  opera- 
tions, 736 
Rupture  of  membranes,  506 

in  induction  of  abortion,  659 
Rupture  of  perineum,  480' 

of  uterus,  abnormalities  causing, 
466 
diagnosis,  472 

intra-uterine    manipulations 
causing,  465 
-  involving  lower  segment  and 
cervix,  470 
mechanism,  463 
morbid  anatomy  of,  468 
operative  treatment,  477 
.    risks  of,  473 

spontaneous,  463,  468 
symptoms,  472 
through  Csesarean  scar,  467 
traumatic,  462 
treatment  of,  474,  476 
of  veins,  479 
tubal,  180 

Sacrum,  breech  presentations  and,  361 
Saline  solution,  injections  of,  in  con- 
vulsions of  eclampsia,  533 

in  post -par  turn  haemorrhage,  526 
Sahne  transfusion  in  eclampsia,  533 
Salpingitis,  chronic,  171 
Salpingo-oophoritis,  596 
Sanger's  method  in  Caesarean  section, 

719 
Saprsemia,  576,  578,  585 

chart  of  case  of,  580 

in  the  puerperium,  579 
Saprophytic  organisms,  564 
Schultze  s  method  of  artificial  respira- 
tion, 636,  637 
Scohotic  pelvis,  431 
Sepsis,  umbihcal,  646 
Septic  abortion,  236 
Septic^naia,  577,  581,  585 

diagnosis  of,  584 

in  puerperium,  581 


Septicsemia — contd. 
onset  of,  581 
prognosis  of,  586 
temperature  in,  582 
treatment  of,  587 
general,  593 
specific,  590,  592 
surgical,  593 
types  of,  treatment,  587 
Serum  reactions  in  pregnancy,  80 
Sex  of  twins,  98 

Shock,  Crile's  method  of  prevention, 
723 
in   intra-peritoneal  haemorrhage, 

189 
prevention  of,  503,  507 
surgical,  532 
Shoulder  presentation,  dorso-posterior 
position,  378 
impacted,  384 
mechanism  in,  380 
presentations,  377 
causes,  378 
management  of,  382 
occurrence,  377 
Shoulders,  dehvery  of,  365 
in  normal  labour,  332 
Shoulders,  impacted,  381,  384 

position     of,    before     and    after 
external  rotation,  302,  303 
"  Show  "  in  normal  labour,  244 
Sialorrhoea,  131 
Sims'  speculum,  232 
Skin  changes  in  pregnancy,  72,  74 
Skull,  fissured  fracture  of,  644 
foetal,  268 
hydrocephalic,  458 
See  also  Foetal  Head. 
Skutsch  pelvimeter,  407 
Smelhe  grip,  370 
Souffle,  funic,  95 

uterine,  93 
Soxhlet's  milk  steriUser,  625 
Speculum,  Sims',  232 
Spec's  human  o\nim,  27 
Spermatozoa,  activity  of,  9 
Spine,     lumbo-sacral,     with     normal 

pelvis,  402 
Spirocheta  palUda  in  placental  tissiie, 

167 
Spleen,  changes  in,  in  eclampsia,  119 
Spondylolisthesis,  sacrum  and  lumbar 

vertebrae  in,  430 
Spondylohsthetic  pelvis,  431 
Stages  of  labour.      See  under  Labour. 
Sterilisation,  obstetric,  309 
of  abdominal  wall,  726 
of  milk,  623 
Sterihser,  obstetric,  309 
Sterihty,  gonorrhoea  and,  203 

question  of,  after  Caesarean  sec- 
tion, 734 
StiU-birth,  633 


INDEX 


775 


Stimulants,  cardiac,  526 
Stools,  infant,  character  of,  620 
Streptococcus  infection,  566,  570 
Striae  albicantes,  75 
Striae  gravidarum,  75 
Subcutaneous  transfusion  in  eclamp- 
sia, 534 
Suckling,  contra-indications  for,  617. 

See  also  Lactation. 
Superfecundation,  100 
Superfoetation,  100 
Sutures,  foetal,  269 

in  Csesarean  section,  730 
Sylvester's  method  of  artificial  respira- 
tion, 638 
Symbiosis,  harmonious,  79 
Symphysiotomy,  721,  749,  754 

indications  for,  750 

open  method,  751 

prognosis  of,  753 

statistics  of,  752 

subcutaneous  method,  752 
Symphysis,  depth  and  thickness  of, 

406 
Syncope,  sudden  death  from,  in  the 

puerperium,  613 
Syncytiolysin,  81 
Syncytioma  malignum,  607 
Syncytium,  19,  32 

entrance    into    maternal    blood, 
112 
Syphilis,  abortion  due  to,  202 

Colles'  law  in,  201 

conceptional,  201 

exciting  cause  of  abortion,  220 

foetal,  201 

infantile,  650 

maternal,  201 

paternal,  200 

placental,  166 

pregnancy  and,  200 


Tbachek-Beyce  ovum,  16 
Temperature  in  the  puerperium,  543 

evanescent  rise  of,  544,  577 

in  septicaemia,  582 

rise  of,  due  to  reaction,  543 
during  abortion,  233 
Thrombo-phlebitis  in  the  puerperium, 

597 
Thrombosis  in  eclampsia,  119 

of  uterine  vessels,  methods  of  pro- 
moting, 524 
Tongue  traction  in  artificial  respira- 
tion, 638 
Toxaemia,  chorionic,  112 

complex,  121,  531 

during  pregnancy,  80,  108 

maternal.  111 

of  eclampsia,  532 

placental,  112,  122,  531 

treatment  of,  536 


Toxfemic  vomiting,  127 

•  clinical  features  of,  128 
Toxic  bodies,  nature  of,  111 

symptoms    of    eclampsia,    treat- 
ment, 536 
Traction,  direction  of,  710 
Traction-rods,  position  of,  708 
Transfusion,  subcutaneous,  in  eclamp- 
sia, 534 
Transmission  of  disease  from  mother 

to  fcetus,  168 
Transverse  presentation,  674 

delivery  by  spontaneous   expul- 
sion, 385 
Transverse  or  shoulder  presentations 
in  abnormal  labour,  377 
seizing  a  foot  in,  681,  683 
Trilaminar  blastoderm,  12 
Triplets,  103 

frequency  of,  97 
Trophoblast,  12 

activity  of,  19 
Tubal  abortion,  174,  178 

with  haematosalpinx,  186 
Tubal  mole,  174 
pregnancy,  171 
anatomy,  171 
clinical  features  of,  185 

aiter  occurrence   of  in- 
ternal bleeding,  187 
before  occurrence  of  in- 
ternal     haemorrhage, 
185 
diagnosis  of,  192 

in  internal  bleeding,  190 
terminating  in  abortion,  177 
rupture,  174,  180 

intra-peritoneal,  180 
Tubercle  of  placenta,  166 
Tubercles  of  Montgomery,  73 
Tuberculosis  complicating  pregnancy, 

200 
Tumours,  Caesarean  section  indicated 
by,  722 
fibroid,  labour  obstructed  by,  436 
of  gravid  uterus,  215 
of  pelvic  bones,  432 
ovarian,  433 

uterine,  pregnancy  and,  435 
treatment,  437 
Twin  labour,  386 

general  course,  387 
management,  388 
presentation  in,  386 
Twin  locking,  387 
placentae,  98 
pregnancy,  91 

cUnical  course  of,  101 
.sex  of,  98 
Twins,  binovular,  97 
development  of,  98 
diagnosis  of,  387 
uniovular,  97,  99 


776 


IXDEX 


Umbilical  cord.     See  under  Cord, 
sepsis,  646 
vein,  anatomy  of,  58 
vesicle,  51 
.Ursemia  in  pregnancj-,  206 
Ursemic  convulsions,  529 

theory  of  eclampsia,  124 
Ureteral  pressure,  124 
Urinary  changes  in  albuminuria,  115 
excretion  of  nitrogen,  109 
tract,  iDacillus  coli  infection  of,  207 
Urine,  acid,  210 

examination  of,  207 
excretion  of,    during   pregnancy, 
78 
in  the  puerperium,  545 
Urotropin,  urinary  antiseptic,  210 
Urotoxic  dose,  80 
Uterine  axis,  misdirection  of,  466 

cavity,   plugging   of  for  haemor- 
rhage, 524 
contractions,  70 

accidental    haemorrhage    ar- 
rested by,  500 
painful  (labour  pains),  243 
sign  of  pregnancv,  90 
dilatoi%  Fenton's,  233 
inertia,  expulsion  of  placenta  pre- 
vented by,  511 
in  labour,  443 
predisposing  causes,  519 
treatment,  444 
infection,  576 

onset  of,  577 
moles,  143 

symptoms,  148 
mucosa,    changes    of,    in    puer- 
perium, 553 
muscle,  changes  in,  68 

excessive  retraction  of,  449 
general  tonic  contraction  of. 

449,  452 
local  tonic  contraction  of,  450 
over-action  of,  449 
souffle,  sign  of  pregnancy,  93 
tumours,  pregnancy  and,  435 

treatment,  437' 
vessels,    changes    of,    in     puer- 
perium, 553 
Uterus,  abnormahties  of,  466 

action    of,    abnormalities    in,    in 

abnormal  labour,  442 
bicornis,  141 

■R-ith  rudimentary'  horn,  142 
bi-manual    compression    of,    for 

haemorrhage,  523 
cervix.     See  under  Cervix, 
changes  in,  in  eclampsia,  117 
chorion  left  in,  513 
clearing  out  of,  for  hfemorrhage, 

523 
compression  of  fundus  of,  336 
contraction  ring  of,  452,  453,  513 


Uterus — contd. 

contractions  of,  in  labour,  273 

in  pregnancv.  90 
didelphys,  141 
diminution  after  third  stage  of 

labour,  253 
double,  141 
drugs  influencing,  231 
evacuation     of,     immediate,     in 

abortion.  235 
exciting  of,  cause  of  abortion,  220 
exhaustion  of,  causes  of,  518 
fibroids  of,  diagnosis  of,  136 
forty  hours  after  dehvery,  550 
gravid,  62 

anteflexion  of,  139 
at  end  of  third  month,  486 
at  term,  frozen  section  of,  67 
backward    displacement    of, 
132 
clinical  course  and  re- 
sults, 134 
diagnosis,  135 
difierential  diagnosis, 136 
treatment,  137 
changes  in,  62 
changes  in  relations,  66 
hernia  of,  140 
lateral  obhquity  of,  66 
measurements  of,  65 
prolapse  of,  140 
removed  for  a  fibroid  tumour, 

485 
retroversion  of,  194 
showing     decidual     haemor- 
rhage, 224 
thickness  of  wall,  68 
tumours  of,  215 

chnical  course,  216 
management,  217 
hour-glass,  contraction  of,  513 
incarceration  of,  134 
incision  of,  727 

closing  of,  729 
inertia  of,  410 

infection  of,  removal  of  organ,  724 
injury  to,  cause  of  abortion,  219 
inversion  of,  in  labour,  480 
prognosis,  482 
symptoms,  481 
involution  of,  in  the  jj'Jerperium, 

548 
local  toxic  contraction  of,  451 
lower  segment,  and  cervix  in  nor- 
mal labour,  274 
measurements,  69,  276 
over-distension  of,  463 
malformation  of,  and  pregnancy, 

141 
mahgnant  disease  of,  pregnancy 

and, 217 
manij)ulation   of,   per   abdomen, 
521 


INDEX 


777 


uterus — contd. 

membranes  of,  affected  by  ovum, 
22,26 

in  normal  labour,  273 

in  puerperal  infection,  571 

obliquity  of,  in  normal  labour,  294 

palpation  of,  315 

plugging  of,  524 

polarity  of,  277 

pressure   within,   direct  and   in- 
direct, 284 

primary  inertia  of,  438 

removal  of,  after  Csesarean  sec- 
tion, 724 

retraction  ring,  irregular,  517 

retracting  wall  of,  276 

right  lateral  obliquity  of,  92 

ring  of,  275 

in  normal  labour,  275 

rupture  of,  462,  474 

size  of,  in  hj^dramnios,  160 

structural  changes   in,   in   puer- 
perium,  552 
in  third  stage  of  labour,  281, 
283 

treatment  of,  in  Cassarean  section, 
732 

two  and  a  half  days  after  delivery, 
551 

See  also  under  Uterine. 

Vaccine  treatment  of  septicsemia,  592 
Vaccines,  autogenous,  210 
Vagina,  bacteriology  of,  554 
douching  after  labour,  556 
examination   by,  during  labour, 
321,  347 
in  retroflexion,  135 
injuries  to,  by  forceps,  718 
lacerations  of,  478 

and  puerperal  infection,  574 
plugging  of,  506,  508 
preparation  for  hysterectomy,  725 
veins  of,  rupture,  479 
Vaginal  Caesarean  section,  735 

in  induction  of  abortion,  668 
Vaginitis,  gonorrhoeal,  203 
Varicose  veins,  142 

in  pregnancy,  206 
Veins,  foetal,  60 

pelvic,  infection  of,  in  puerperal 
infection,  575 
ligature    or    excision    of,  in 
pyaemia,  602 
of  vagina,  rupture  of,  479 
Veit-Mauriceau   grip   in   breech   pre- 
sentations, 369, 370, 371 
Velamentous  placenta,  163,  165 
Venereal  diseases,  influence  on  preg- 
nancy, 201 
Venesection  in  eclampsia,  533 
Venous  system  in  pregnancy,  76 
Ventral  stalk,  His's,  51 


Vernix  caseosa,  removal  of,  615 
Version,  bi-polar  or  combined,  687 
external  in  breech  presentation, 
367,  672 
of  foetus  in  utero,  671 
internal,  difficulties  of,  686 
of  foetus  in  utero,  675 
prehminaries,  681 
steps  of  operation,  682 

for  transverse  presenta- 
tion, 682 
in  placenta  prsevia,  505 
podalic,  in  prophylactic  manage- 
ment in  contracted  pelvis,  418 
rupture  precipitated  by,  385 
spontaneous,  in  shoulder  presen- 
tation, 380 
Vertex,  occipito-posterior  positions  of 
in  normal  labour,  299,  337 
presentation  in  normal  labour, 
286 
in  twin  labour,  386 
moulding  of  head  in,  305 
positions  of,  295, 306, 318,324 
Vesicular    degeneration    of,    chorion, 
148,  151 
mole,  148 

in  situ,  150 
Viability  of  foetus,  57 
Villi  atrophied,  42 

chorionic,  41,  153 
fully  formed,  34 
placental,  36 

sho^nng   proliferation  of   syncy- 
tium, 32 
Vomiting,  associated,  126 
diagnosis  of,  129 
hysterical,  126 
pernicious,  126 
toxaemic,  127 
treatment  of,  130 
Vulva,  disinfection  of,  in  management 
of  normal  labour,  308 
laceration  of,  and  puerperal  in- 
fection, 574 
Vulvo-vaginitis,  gonorrhoeal,  202 

Walchee's  position,  axis-traction  for- 
ceps in,  712 
in  generally  contracted  pelvis,  713 
"Waters,"  bag  of,  formation  of,  246^ 

272 
Wedge  theory,  294 
Weight  of  foetus,  57 
Weight  of  infant,  620 
Wet-nursing,  627 
Wharton's  jelly,  238 

showing  stellate  cells,  53 
White  leg,  598 

Wounds,  as  channels  of  infection  in 
puerperal  infection,  569 

Zygote,  10,  11 


BRADBURY,    AGNEW,    &    CO.    LD.,    PRINTERS,    LONDON   AND   TONBRIDflk:. 


E.M. 


50 


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